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Drawbacks exist with the standard treatment (four-layer compression bandages) for venous leg ulcers. We have therefore compared the clinical effectiveness and cost-effectiveness of two-layer compression hosiery with the four-layer bandage for the treatment of such ulcers. We undertook this pragmatic, open, randomised controlled trial with two parallel groups in 34 centres in England and Northern Ireland. The centres were community nurse teams or services, family doctor practices, leg ulcer clinics, tissue viability clinics or services, and wound clinics. Participants were aged 18 years or older with a venous leg ulcer and an ankle brachial pressure index of at least 0·8, and were tolerant of high compression. We randomly allocated participants (1:1) to receive two-layer compression hosiery or a four-layer bandage, using a remote randomisation service and prevalidated computer randomisation program. Participants were stratified by ulcer duration and ulcer area with permuted blocks (block sizes four and six). The primary endpoint was time to ulcer healing, with a maximum follow-up of 12 months. Although participants and health-care providers were not masked to treatment allocation, the primary endpoint was measured by masked assessment of photographs. Primary analysis was intention to treat with Cox regression, with adjustment for ulcer area, ulcer duration, physical mobility, and centre. This trial is registered with the ISRCTN register, number ISRCTN49373072. We randomly allocated 457 participants to the two treatment groups: 230 to two-layer hosiery and 227 to the four-layer bandage, of whom 453 (230 hosiery and 223 bandage) contributed data for analysis. Median time to ulcer healing was 99 days (95% CI 84–126) in the hosiery group and 98 days (85–112) in the bandage group, and the proportion of ulcers healing was much the same in the two groups (70·9% hosiery and 70·4% bandage). More hosiery participants changed their allocated treatment (38·3% hosiery vs 27·0% bandage; p=0·02). 300 participants had 895 adverse events, of which 85 (9·5%) were classed as serious but unrelated to trial treatment. Two-layer compression hosiery is a viable alternative to the four-layer bandage—it is equally as effective at healing venous leg ulcers. However, a higher rate of treatment changes in participants in the hosiery group than in the bandage group suggests that hosiery might not be suitable for all patients. NIHR Health Technology Assessment programme (07/60/26).

Venous leg ulcer recurrence can be prevented with daily compression stocking wear; however, stocking effectiveness is often hindered by poor patient adherence. The ‘Personalised and Multi‐dimensional Compression Assessment and Intervention’ (PAMCAI) is a multidimensional decision aid, delivered by clinicians via an iPad application, designed to improve adherence. This study piloted the methodology and feasibility of PAMCAI's efficacy and cost‐effectiveness for evaluation in a larger randomised controlled trial (RCT). Using a two‐arm, single‐blinded pilot RCT with cost‐utility analysis, PAMCAI was compared with usual care in a tertiary hospital occupational therapy outpatient clinic. The primary outcome was adherence to wearing compression stockings, measured on a 4‐point scale. Twenty participants were randomised to receive PAMCAI (n = 10) or usual care (n = 10). Recruitment and pilot methodology appear feasible for use in a larger study. Compression stocking adherence was greater with PAMCAI compared to usual care (p = 0.002) and PAMCAI is likely cost‐effective, with an incremental cost‐effectiveness ratio of $3379.36 per quality‐adjusted life year (QALY) gained. Resolution of identified barriers to stocking adherence was positively associated with improvements in patient adherence. These findings support further investigation of PAMCAI in a larger RCT and its potential to improve patient adherence and the cost‐effectiveness of compression therapy for venous leg ulcer prevention.

Deep vein thrombosis (DVT) and pulmonary embolism are common after stroke. In small trials of patients undergoing surgery, graduated compression stockings (GCS) reduce the risk of DVT. National stroke guidelines extrapolating from these trials recommend their use in patients with stroke despite insufficient evidence. We assessed the effectiveness of thigh-length GCS to reduce DVT after stroke. In this outcome-blinded, randomised controlled trial, 2518 patients who were admitted to hospital within 1 week of an acute stroke and who were immobile were enrolled from 64 centres in the UK, Italy, and Australia. Patients were allocated via a central randomisation system to routine care plus thigh-length GCS (n=1256) or to routine care plus avoidance of GCS (n=1262). A technician who was blinded to treatment allocation undertook compression Doppler ultrasound of both legs at about 7–10 days and, when practical, again at 25–30 days after enrolment. The primary outcome was the occurrence of symptomatic or asymptomatic DVT in the popliteal or femoral veins. Analyses were by intention to treat. This study is registered, number ISRCTN28163533. All patients were included in the analyses. The primary outcome occurred in 126 (10·0%) patients allocated to thigh-length GCS and in 133 (10·5%) allocated to avoid GCS, resulting in a non-significant absolute reduction in risk of 0·5% (95% CI −1·9% to 2·9%). Skin breaks, ulcers, blisters, and skin necrosis were significantly more common in patients allocated to GCS than in those allocated to avoid their use (64 [5%] vs 16 [1%]; odds ratio 4·18, 95% CI 2·40–7·27). These data do not lend support to the use of thigh-length GCS in patients admitted to hospital with acute stroke. National guidelines for stroke might need to be revised on the basis of these results. Medical Research Council (UK), Chief Scientist Office of Scottish Government, Chest Heart and Stroke Scotland, Tyco Healthcare (Covidien) USA, and UK Stroke Research Network.

Reduced venous return is an important trigger of vasovagal syncope (VVS). Elastic compression stockings (ECS) can modify venous return and be of therapeutic interest; however, evidence for ECS efficacy in VVS is scarce. This randomized controlled trial was designed to address the issue. COMFORTS-II is a multicenter, triple-blind, parallel design, randomized controlled trial aimed to assess the efficacy of ECS in preventing VVS recurrences. Using central online randomization, 268 participants will be allocated to 2 arms (1:1 ratio), wearing intervention ECS (25-30 mm Hg pressure) or sham ECS (≤10 mm Hg pressure). All participants will receive standard VVS treatment in the form of education, and lifestyle modification recommendations (drinking 2-3 l/d of fluids and consuming 10 g/d—roughly half a tablespoon—of table salt). Adherence to ECS treatment will be evaluated through diary sheets, and compared between study arms. Follow-up continues for 1 year, and is conducted via a 24/7 phone line available to patients and trimonthly visits. The co-primary outcomes are proportion of participants with any syncopal recurrence and time to first syncopal episode. Secondary outcomes include frequency of VVS spells, time intervals between recurrences, and incidence of any patient-reported adverse effects. To the best of our knowledge, COMFORTS-II is the first clinical trial to assess ECS efficacy among patients with VVS, addressing an important gap in evidence for VVS treatments.

Background Venous thromboembolism (VTE) is a significant complication following total knee arthroplasty (TKA), with considerable implications for patient outcomes. The purpose of this study is to assess the incidence of VTE after fast-track TKA at our center and to evaluate whether the use of graded compression stockings (GCS) can further reduce VTE incidence within this regimen. Methods A total of 660 patients undergoing primary TKA between January 1, 2018, and December 31, 2022, were included. Patients were categorized into two groups: GCS group ( n  = 390) and non-GCS group ( n  = 270). Knee-length GCS were applied to patients in the GCS group. Diagnosis of deep vein thrombosis (DVT) was confirmed by bilateral lower extremity duplex venous ultrasonography. Incidence and locations of thrombosis were recorded. Demographic characteristics, laboratory indices, and surgical variables were collected. Univariate and multivariate regression analyses were performed to identify risk factors for thrombosis. Results The overall incidence of VTE after fast-track TKA was 6.2% (41/660), with no cases of proximal DVT or pulmonary embolism (PE). The incidence of DVT was significantly lower in the GCS group compared to the non-GCS group (3.8% vs. 9.6%). After adjusting for confounders, multivariate analysis demonstrated that absence of GCS, older age, and history of cardiovascular disease were independent risk factors for postoperative DVT. Conclusion In conclusion, this study found a low incidence of VTE after fast-track TKA, and the use of GCS may further reduce the occurrence of early postoperative calf muscular vein thrombosis (CMVT) when combined with anticoagulants plus intermittent pneumatic compression (IPC).

Figure 2 summarizes the mechanisms of action of graduated compression stockings. The stockings work by exerting the greatest degree of compression at the ankle, with the level of compression gradually decreasing up the garment. The pressure gradient ensures that blood flows upward toward the heart instead of refluxing downward to the foot or laterally into the superficial veins. The application of adequate graduated compression reduces the diameter of major veins, which increases the velocity and volume of blood flow.2 Graduation compression can reverse venous hypertension, augment skeletal-muscle pump, facilitate venous return and improve lymphatic drainage.3 It also initiates complex physiologic and biochemical effects involving the venous, arterial and lymphatic systems, although the exact mechanisms remain unclear.2,4,5 One study that used near-infrared spectroscopy to monitor changes in tissue oxy hemo - globin and deoxyhemoglobin re ported that limb oxygenation increased with the use of graduated compression stockings, especially with highcompression stockings.4 Another study showed that levels of proinflammatory cytokines (e.g., interleukin-1α, interleukin-6 and interferon-γ) in ulcer tissue in patients with active ulcers were significantly reduced following compression therapy.5 Although we found no RCT that compared compression with no compression in patients with venous skin changes (CEAP class C4), it is generally accepted that the management of such patients should include graduated compression stockings if tolerated.1,20 There is high-quality evidence that venous ulcers heal more rapidly with than without compression therapy.1,21,22 Patients with venous ulcers are often treated with compression bandages. However, there is some evidence that graduated compression stockings are equally effective.22,23 A meta-analysis of eight RCTs (n = 692) reported that the proportion of ulcers that healed was significantly higher with graduated compression stockings than with bandages (62.7% v. 46.6%).23 The average time to ulcer healing was also significantly shorter with the stockings, by three weeks. Graduated compression stockings may also be associated with less pain than bandages are.21,23 A systematic review of graduated compression stockings for the prevention of deep vein thrombosis in patients admitted to hospital because of conditions other than stroke identified 18 RCTs.29 Graduated compression stockings were used alone or in combination with another form of prophylaxis (e.g., heparin, acetylsalicylic acid and sequential compression). All but one of the RCTs assessed surgical patients. Deep vein thrombosis was diagnosed mostly through screening with ultrasonography, venography or isotope studies. Deep vein thrombosis developed in 13% of patients given graduated compression stockings, as compared with 26% of those with no stockings. In the trials in which stockings were given in combination with another prophylactic method, deep vein thrombosis developed in 4% of patients given the stockings plus another method, as compared with 16% of those given the other method alone. It was concluded that graduated compression stockings were effective in reducing the risk of deep vein thrombosis among patients in hospital, especially when used with another method of prophylaxis.29

This qualitative study aimed to describe users’ experiences and needs related to wearing, donning, and doffing compression hosiery, and the provision process of compression hosiery and associated assistive products for donning and doffing. Adults who have been advised to wear compression hosiery participated in semi-structured interviews. Existing frameworks about the provision process and acceptance of assistive technology guided the topic list. The interviews were analyzed using directed content analysis. After 19 interviews, data saturation was reached. Three main themes were revealed: (1) becoming and being a compression hosiery wearer (or not), (2) wearing compression hosiery, and (3) donning and doffing compression hosiery. In cases of acute conditions, the participants reported feeling overwhelmed when they were first prescribed compression hosiery. In contrast, those with long-term complaints felt relieved. Participants considered advantages and disadvantages and then decided whether to wear compression hosiery. Despite mentioned beneficial effects from wearing compression hosiery, participants had to cope with a range of discomforts, including pinching, straining, sagging, and heat. Additionally, participants had difficulties with the appearance, and often tried to hide the compression hosiery. They mentioned problems with donning and doffing, which can result in dependency of home or informal care, which stopped some participants from wearing. In general, participants were not aware of the full range of assistive products for donning and doffing, but were interested in them. In conclusion, wearing compression hosiery has a large impact on a person’s life because of its lack of comfort, unattractive appearance, and possible loss of independence through the need of donning and doffing support. These are expressed reasons for non-adherence, in addition to a lack of understanding of the importance of wearing and the consequences of not wearing compression hosiery. Easy-to-find independent information and more attention to donning and doffing during the fitting appointment of compression hosiery are recommended.

PurposeHospitalisation and surgery are major risk factors for venous thromboembolism (VTE). Intermittent pneumatic compression (IPC) and graduated compression stockings (GCS) are common mechanical prophylaxis devices used to prevent VTE. This review compares the safety and efficacy of IPC and GCS used singularly and in combination for surgical patients.MethodsOvid Medline and Pubmed were searched in a systematic review of the literature, and relevant articles were assessed against eligibility criteria for inclusion along PRISMA guidelines.ResultsThis review is a narrative description and critical analysis of available evidence. Fourteen articles were included in this review after meeting the criteria. Results of seven studies comparing the efficacy of IPC versus GCS had high heterogeneity but overall suggested IPC was superior to GCS. A further seven studies compared the combination of IPC and GCS versus GCS alone, the results of which suggest that combination mechanical prophylaxis may be superior to GCS alone in high-risk patients. No studies compared combination therapy to IPC alone. IPC appeared to have a superior safety profile, although it had a worse compliance rate and the quality of evidence was poor. The addition of pharmacological prophylaxis may make mechanical prophylaxis superfluous in the post-operative setting.ConclusionIPC may be superior to GCS when used as a single prophylactic device. A combination of IPC and GCS may be more efficacious than GCS alone for high-risk patients. Further high-quality research is needed focusing on clinical relevance, safety and comparing combination mechanical prophylaxis to IPC alone, particularly in high-risk surgical settings when pharmacological prophylaxis is contraindicated.

Functional proprioceptive information is required to allow an individual to interact with the environment effectively for everyday activities such as locomotion and object manipulation. Specifically, research suggests that application of compression garments could improve proprioceptive regulation of action by enhancing sensorimotor system noise in individuals of different ages and capacities. However, limited research has been conducted with samples of elderly people thus far. This study aimed to examine acute effects of wearing knee-length socks (KLS) of various compression levels on ankle joint position sense in community-dwelling, older adults. A total of 26 participants (12 male and 14 female), aged between 65 and 84 years, were randomly recruited from local senior activity centres in Singapore. A repeated-measures design was used to determine effects on joint position awareness of three different treatments–wearing clinical compression socks (20–30 mmHg); wearing non-clinical compression socks (< 20 mmHg); wearing normal socks, and one control condition (barefoot). Participants were required to use the dominant foot to indicate 8 levels of steepness (2.5°, 5°, 7.5°, 10°, 12.5°, 15°, 17.5°, and 20°), while standing on a modified slope box, in a plantar flexion position. Findings showed that wearing clinical compression KLS significantly reduced the mean absolute errors compared to the barefoot condition. However, there were no significant differences observed between other KLS and barefoot conditions. Among the KLS of various compression levels, results suggested that only wearing clinical compression KLS (20–30 mmHg) improved the precision of estimation of ankle joint plantar flexion movement, by reducing absolute performance errors in elderly people. It is concluded that wearing clinical compression KLS could potentially provide an affordable strategy to ameliorate negative effects of ageing on the proprioception system to enhance balance and postural control in community-dwelling individuals.

The aim of this study was to evaluate changes in electromyographic activity with the use of gradual compression stockings (GCSs) on middle-distance endurance athletes’ performance, based on surface electromyography measurement techniques. Sixteen well-trained athletes were recruited (mean ± SD: age 33.4 ± 6.3 years, VO2max 63.7 ± 6.3 mL·kg−1·min−1, maximal aerobic speed 19.7 ± 1.5 km·h). The athletes were divided into two groups and were assigned in a randomized order to their respective groups according to their experience with the use of GCSs. Initially, a maximum oxygen consumption (VO2max) test was performed to standardize the athletes’ running speeds for subsequent tests. Afterward, electromyographic activity, metabolic, and performance variables for each group were measured with surface electromyography. In addition, blood lactate concentration was measured, both with and without GCSs, during 10 min at 3% above VT2 (second ventilatory threshold), all of which were performed on the track. Next, surface electromyography activity was measured during a 1 km run at maximum speed. No significant changes were found in electromyography activity, metabolic and performance variables with GCSs use (p > 0.164) in any of the variables measured. Overall, there were no performance benefits when using compression garments against a control condition.