Effects of bandage types on interface pressure in static positions and during walking

Abstract

The main objective of this study was to compare the interface pressure applied by four different compression bandages (two elastic, one inelastic, and one multi-layer system), in various static and dynamic conditions and over time. The second objective was to compare their Static Stiffness Index and their Dynamic Stiffness Index. The compression bandages were applied on 20 legs of healthy females. Interface pressure was measured at two different points of the leg (ankle and calf), at rest in two positions (standing, supine), and during walking sequences. Interface pressure depends mainly on the mechanical properties of compression devices and on the subject morphology. Both elastic and multilayer compression devices exhibited a pressure gradient loss from the ankle to the calf. Over time, pressure loss was higher for inelastic compression bandages (p < 0.001) than for elastic and multilayer compression systems. Pressure variation from a supine to a standing position, and during walking, was higher for both inelastic bandage and multilayer system, than for elastic bandages (p < 0.01) whatever the measurement time and the measurement point. For all compression devices, pressure variation during walking at the ankle was about 25% of the pressure variation when switching from a supine to a standing position. These results provide a better understanding of the behavior of various bandage types. The pressure variations measured during walking are lower than those obtained when the subject switches from a supine to a standing position. This study suggests that the efficacy of compression bandages relies on the interface pressure that they exert on the legs, and the capacity of the patient to walk, which activates calf muscle.

Keywords

Interface pressure walking elastic compression bandage inelastic bandage multi-layer compression system stiffness

Introduction

Numerous venous, lymphatic, and trauma conditions are treated with medical compression bandages.^1–3 The efficacy of compression treatment depends on whether adequate pressure is applied, as well as on the bandage’s ability to maintain this pressure over time.

Besides their diverse mechanical characteristics, these bandages can be applied on their own in the conventional manner (single-layer systems) or as combinations (multi-layer systems). It is often difficult to determine the pressure applied by these compression devices. The relationship between the tension of the bandage (T), the local curvature (r), the number of layers (n), and the local interface pressure (P) is given by Laplace’s law.

P = n \times T / r

(1)

Therefore, the interface pressure depends not only on the applied tension and the patient morphology^4,5 but also on the application techniques, the behavioral characteristics that vary widely from one system to another,^2,6,7 and the tribological properties of the bandage.⁸

Compression bandage systems are sometimes classified based on their extension capacity (short, medium, or long)⁹ and sometimes according to their behavior (rigid, inelastic, or elastic).⁹ The elasticity is the ability of an object or material to resume its normal shape after being stretched or compressed. Most recently, compression systems have been classified according to their Static Stiffness Index (SSI). This represents the interface pressure variation in the gaiter area while standing up from a supine position.⁹ Compression bandages systems have been classified in two different categories depending on SSI. If SSI is lower than 10 mm Hg, the compression device is considered as elastic, otherwise it is considered as inelastic. The Dynamic Stiffness Index (DSI) represents the pressure variation in the gaiter area while walking.¹⁰ SSI and DSI are supposed to be equal.¹¹ But to our knowledge, the evaluation of the correlation between in vivo measurement of SSI and DSI has never been studied, especially for compression bandages.

The pressure exerted by compression bandage systems was recently studied in vivo and in a static position.^4,5,7,¹² Awareness of a bandage’s profile as to the pressure it generates over time is therefore of primary importance in order to know how much time it takes for the bandage to lose its efficacy and require readjustment, or even replacement. Some studies have identified pressure peaks generated by walking or exercise but very few have dealt with changes in pressure over time,^13–15 much less during walking.¹⁴ Elastic bandages retain pressure over time.¹⁵ Inelastic bandages appear to apply firm intermittent pressure, which is relatively mild at rest and therefore well tolerated, and greater during muscular activity.

The main objective of this study is to measure and compare the interface pressure applied by four types of compression bandages (two elastic bandages, one inelastic bandage, and one multi-layer system) in various conditions (at rest and during walking) and over time. The second objective is to compare SSI and DSI for these compression bandages. These compression bandages are representative of the global market.

Methods

Population

Twenty healthy female participants agreed to participate in this study (Table 1). All of the participants underwent a clinical examination to ensure that they met the following inclusion criteria: healthy, female, no history of pregnancy, 18–30 years of age, and free of: any functional vascular symptoms in the lower limbs; any neurological, rheumatologic, cardiovascular, respiratory illness that could affect the lower-limb vascular system or mobility; any traumatic injury or history of surgery on the lower limbs or pelvis; any functional constraints affecting walking and the ability to move from supine to sitting to standing, unassisted.

Table 1.

Population characteristics

					Perimeter^a
	Age (in years)	Weight (in kg)	Height (in cm)	BMI (in kg.m^–2)	B (in cm)	B1 (in cm)	C (in cm)
Average	21.8	59.1	165.7	21.5	22.3	28.9	35.5
SD	1.9	7.6	5.4	2.2	0.8	1.4	1.5
Min	19.0	46.0	155.0	18.4	21.0	25.3	32.5
Max	27.0	71.0	174.0	24.8	24.5	31.0	37.6

BMI: body mass index; SD: standard deviation.

B1 is where the Achilles tendon turns into the gastrocnemius muscle; C is where the calf circumference is the largest; and B is where the ankle circumference is the smallest.

The study design was conducted according to the Declaration of Helsinki and approved by the Committee for the Protection of Persons (2011-A01426-35). All of the participants, once informed, agreed to sign a consent form.

Bandages

Three compression bandages and a multi-layer system were tested, and applied in accordance with the manufacturer’s indications for application (Table 2).

Table 2.

Compression bandages application techniques recommended by manufacturers and technical characteristics established according to NF S97-115 standard¹⁶

	Composition***	Elastic/inelastic	Application method	Overlap	Extension on application	Physical characteristics
	Composition***	Elastic/inelastic	Application method	Overlap	Extension on application	Weight (g/m²)	Extension on application (%)	Maximum extension (%)	Residual deflection (%)	Traction force when extended on application (N/m)
B16*	Vi/Pes/Pa/El	Elastic	Spiral	50%	30%	314	30	82	3	50
B16*	52.5/37/7.5/3	Elastic	Spiral	50%	30%	314	30	82	3	50
B17*	Vi/Pes/Pa/El	Elastic	Spiral	50%	40%	377	40	85	1.6	117
B17*	55.5/32/6.5/6	Elastic	Spiral	50%	40%	377	40	85	1.6	117
Rosidal® K	Co 100	Inelastic	Spiral	50%	80% of maximum extension	341	71	88	17.3	282
Profore® Kit
Profore® WCL	Vi 100	Inelastic	Spiral	50%	No stretch
Profore® #1	Co 100	Inelastic	Spiral	50%	No stretch
Profore® +**	Vi/Pa/Co/El	Elastic	Figure-eight	NA	50%
Profore® #4	Pa/El	Elastic	Spiral	50%	50%

Marks are printed on the B16 and B17 bandages. They serve as reference points for extension during application and for overlap.

The Profore® + bandage includes a reference point for controlling overlap during figure-eight application.

***

Co : Cotton; El : Elastic material (elasthane, latex, etc.); Pes : Polyester. Pa : Polyamide; Vi : Viscose.

B16: elastic bandage (Thuasne, Levallois-Perret, France).

B17: elastic bandage (Thuasne, Levallois-Perret, France).

RK: Rosidal K inelastic bandage (Lohmann and Rauscher International, Rengsdorf, Germany).

PK: Profore Kit (Smith and Nephew UK, Hull, UK), the Profore 18–25 cm multi-layer compression system.

The B16, B17, and RK bandages were tested in accordance with the AFNOR NF S97-115 standard (Table 2). Tensile elongation behavior of the bandages, is one of their main characteristics as it is directly linked to their elastic/inelastic behavior and to the interface pressure they applied over human segments. The tensile tests were carried out according to the following conditions:

Sample width: 50 mm

Sample length: 200 mm

Pre load: 6 N/cm

Speed: 100 mm/min

Fabric constructions are given in Figure 1 and yarn characteristics in Table 3. Both B16 and B17 have been developed in such a way that their maximum elongation is lower than 100%.

Table 3.

Compression bandages and yarn characteristics

		RK	B16	B17
Warp	Yarn characteristics	1A: Co 100 – Nm 30/2	1B / 2B: Double covered yarnsEl 310 dtex double covered with Pes 167	1B / 2B: Double covered yarnsEl 310 dtex double covered with Pes 167
Warp	Yarn characteristics		3B: Vi 100 – Nm 76/2	3B: Vi 100 – Nm 76/2
Weft	Yarn characteristics	2A: Co 100 – Nm 50/2	4B: Vi Pes 65/35 – Nm 25/1	4B: Vi Pes 65/35 – Nm 25/1

Co: cotton; Pes: polyester; Vi: viscose.

Interface pressure measurements

Pressure measurements were performed on the medial side of the left leg at two measurement points as recommended:¹⁷ point B1 (where the Achilles tendon turns into the gastrocnemius muscle) and point C (at the widest circumference of the calf) (Figure 2). The pressure measurements were taken using the PicoPress (MicroLab Elettronica, Ponte S. Nicolo, Italy) pneumatic measuring system with an acquisition frequency of 4 Hz and a flexible sensor measuring 5 cm in diameter. Sensors were attached to the skin with self-adhesive tape onto the measurement points. In this article, points B1 and C will refer to the measurement area, where the sensors have been positioned.

Walking sequences

The walking sequences were performed on the ADAL treadmill (Techmachine, Andrézieux- Bouthéon-France).¹⁸ The ADAL treadmill is composed of two parallel bands each measuring 1.5 m long and 25 cm wide, separated by a 7 mm space and each mounted on three-dimensional (3D) piezoelectric strain gauges (Kisler type KI 9067, Wintertur, Switzerland).

Interface pressure measurement protocol

The in vivo interface pressures were measured in the supine, standing, and walking positions (Figure 3). The participants performed three successive 15-minute walking sequences at 3 km/h, barefooted, on the ADAL treadmill, with five-minute intervals of rest. This speed matches that of a patient with a slow gait, as venous leg ulcer is often associated with ageing and low mobility.^19–21 For the supine position, participants were lying on a physiotherapist table.

Each participant underwent the evaluation phases over two half-days. The four systems were randomly applied. Each participant wore each system for 65 min (including 45 min walking). The compression bandages were applied by a single trained and qualified investigator, following the instructions for use given by the manufacturers. New bandages were used for each participant.

Interface pressure measurements were taken:

At rest: in standing and supine positions prior to the first walking sequence (R0) and during each of the three resting phases (R1, R2, R3), between the different walking sequences. For each patient, each measuring point and each phase interface pressure was measured three times. R0 corresponds to the resting phase before walking and R1, R2, and R3 correspond to the resting phases after 15, 30, and 45 min walking.

During walking: at the beginning (T0) and at the end (T1) of the first walking sequence; at the end of the second (T2) and the third (T3) walking sequences. Interface pressure was measured continuously during 30 s for each of the four dynamic measurement sequences. This gives 120 data points per sequence. T0 corresponds to the measurement phase at the beginning and T1, T2, T3 correspond to measurement phases after 14 min 30 s, 29 min 30 s, and 44 min 30 s walking.

Main parameters calculated

SSI

SSI = P_{Standing} - P_{Supin e}

(2)

where P_Standing is the interface pressure measured in the standing position (in mm Hg) and P_Supine is the interface pressure measured in the supine position (in mm Hg).

DSI

DSI is the difference between two successive maximum and minimum pressure pics measured during walking. It is expressed in mm Hg.

Gradient pressure from point B1 to C

Gradient pressure = \frac{P_{C} - P_{B 1}}{P_{B 1}} \times 100

(3)

where P_C is the interface pressure measured at point C (in mm Hg) and P_B₁ is the interface pressure measured at point B1 (in mm Hg).

Statistical analysis

The Shapiro and Wilk test was used to verify that the distributions were within the normal range and Fisher’s F test was used to verify the uniformity of the variances.

When the normalcy and uniformity conditions were met, a two-way (time period and bandages) repeated-measurement analysis of variance (ANOVA) parametric test was applied. In cases where the ANOVA test was significant, a Tukey post-hoc test was used. The significance threshold used was p < 0.05.

Results

An ANOVA between the two factors (Figures 4 –7) shows that the pressures exerted differ according to bandage (p < 0.001), time period (p < 0.001), and measurement point.

Interface pressure at rest and during walking

Interface pressure at point B1, in the supine position was found to be similar for B16 and RK, 29.5 ± 3.6 and 31.8 ± 4.7 mm Hg, respectively. B17 and PK exerted a higher pressure than the two other bandages with 48.7 ± 4.2 for B17 and 42.2 ± 9.4 mm Hg for PK.

In the standing position, at point B1, for both PK and B17, the interface pressure was very similar with 60.4 ± 10.6 for PK and 58.0 ± 6.1 mm Hg for B17. Pressure applied by RK was significantly higher than B16 (p < 0.001), 50.5 ± 7.2 and 39.4 ± 5.7 mm Hg, respectively.

During walking, at point B1, the average pressure applied by B16 was lower than all the other bandages (p < 0.001) with 32.4 ± 4.3 whereas it was 35.9 ± 7.6 mm Hg for RK. There was no difference between PK (51.2 ± 11.3 mm Hg) and B17 (51.7 ± 6.2 mm Hg). Whatever the compression system, the average interface pressure during walking is always higher than the interface pressure in the supine position and lower than the interface pressure in the standing position.

Pressure change over time

There was a significant decrease in the resting pressures over time (after 65 min, including 45 min walking) for all bandages, irrespective of position and the measurement point (Table 4).

Table 4.

Pressure loss over time

	Supine position^a		Standing position^a		Walking^b
	B1	C	B1	C	B1	C
B16	−17%	−19%	−11%	−12%	−8%	−9%
B17	−13%	−14%	−10%	−10%	−7%	−7%
PK	−14%	−17%	−5%	−8%	−6%	−6%
RK	−31%	−36%	−13%	−16%	−11%	−13%

Pressure loss compared with R0.

Pressure loss compared with T0.

Pressure loss, whatever the situation was higher at point C than at point B. The pressure loss was higher in the supine position than in the standing position. The pressure loss during walking was lower than at rest. The interface pressure loss was higher for RK than for all the other bandages (up to 36%, at point C, in the supine position) for all position and all measurement points, this pressure loss was quite similar for B16, B17, and PK.

Pressure variation from the supine to the standing position (SSI)

The interface pressures increased significantly from the supine position to the standing position, for all bandages and all measurement points (p < 0.001) (Figure 6). For both PK and the RK, the SSI ranged from 18.2–22.4 mm Hg, while it ranged from 9.2–10.6 mm Hg for B16 and B17. At point C, for both PK and the RK, the pressure variation was between 13.5–17.3 mm Hg, while it was between 6.9–8.7 mm Hg for B16 and B17. SSI was stable over time.

Pressure variation during walking (DSI)

During walking, pressure variations for both PK and RK were similar, and they were significantly higher than for B16 and B17 (p < 0.001) (Figure 7).

For both PK and the RK, the DSI ranged from 4.4–5.0 mm Hg, while it ranged from 2.2–2.8 mm Hg for B16 and B17.

At point C, for both PK and the RK, the pressure variation was between 2.6–3.8 mm Hg, while it was between 1.6–2.4 mm Hg for B16 and B17. Overall, DSI was about 25% of SSI.

Gradient pressure loss

At the beginning of the test, whatever the situation, a gradient pressure loss was measured for elastic compression bandages and the multilayer system (Table 5). For RK, there was a pressure loss from point B1 to point C only in the standing position and there was a pressure increase in the supine position and during walking.

Table 5.

Gradient pressure loss from point B1 to point C^a

	Supine position^a	Standing position^a	Walking^b
B16	−4%	−10%	−4%
B17	−3%	−9%	−3%
PK	−8%	−13%	−12%
RK	10%	−6%	6%

Measured at R0.

Measured at T0.

Tensile strength/elongation behavior

Elastic and inelastic bandages exhibited two different tensile strength/elongation behaviors (Figure 8 and Figure 9): the same elongation variation led to a higher tension variation for the inelastic bandage than for the elastic bandage.

Discussion

The results of this comparative study of four different bandages exhibiting elastic and inelastic show significant differences in behavior for the pressure exerted over time, the gradient pressure loss, and the stiffness index.

Interface pressure at rest and during walking

Whatever the position (supine, standing, walking), the measurement time and the measurement point, pressure applied by B17 is always higher than for B16. These results are in line with previous reports.^4,5 Because the tension under application of B16 is lower than for B17, the applied pressure by B16 is lower.

The average pressure during walking is always higher than the interface pressure in the supine position, and lower than the interface pressure in the standing position, whatever the measurement time and the measurement point.

Changes in pressure over time

Pressure loss over time is significantly higher for inelastic bandages than for elastic ones. The pressure loss is higher in the supine position than in the standing position.

These results are consistent with previous results.^14,15,22 Pressure loss over time is due to the mechanical behavior of compression bandages. Elastic bandages are recovering their initial dimension after having been stretched, while non-elastic bandages will exhibit a residual defection. Drean et al.²³ have shown that the tension loss of both B16 and B17 is about 10% after 1 h under the application elongation, whereas it is about 50% for RK.

Pressure variation from the supine to the standing position and pressure variation during walking

DSI was on average equal to 25% of SSI. Since interface pressure is not correlated to soft tissue mechanical properties, this finding can be explained by variations of the volume of the legs which are lower (and not similar) than the variation when switching from a supine to a standing position. When changing position from supine to standing, and during walking, two phenomena are occurring: muscle contractions (mainly gastrocnemius) and variations of the volume of the legs.

Recent findings have shown with both numerical simulation⁸ and interface pressure measurement²⁴ that the interface pressure is poorly correlated to the soft tissue mechanical properties.

Stick et al.^25,26 have demonstrated that in the lying position, the volume of the leg is decreasing while in the standing position it is increasing. They also found that during walking, the changes in the volumes depend on the walking speed.²⁷ At 3 km/h the leg volume decreases in two steps. During the first 2 min, it decreases by about 1.5%, and then during the second period, the volume decreases less to reach about 2.5% after 15 min. At 6 km/h, there is no significant decrease of the volume of the leg.

These pressure difference between the supine position, the standing position, and during walking can be explained by the changes of the volume of the legs. When walking at 3 km/h, the volume of the leg is higher than in the supine position, and lower than in the standing position.²⁸

SSI and DSI are higher for the inelastic bandage and multi-layer system, whatever the measurement point and the time. The results obtained for SSI are similar to previous studies. The same volume variation of the leg leads to the same elongation variation for elastic and inelastic bandages, but to a higher tensile strength variation, and therefore to a higher interface pressure variation, for the inelastic bandage than for the elastic bandage. This is due to their mechanical behavior which is different. SSI is higher than 10 mm Hg for inelastic bandages and multi-layer system, and lower than 10 mm Hg for elastic bandages.^4,5,7,9 The interface pressure variations measured during walking are different from previous ones.

Pressure variations observed during walking, at point C, are in the same range as the results obtained by Hirai.²⁹ But the SSI values are different. In this study the measuring device was different and the diameter of the probe was 2 cm instead of 5 cm in our case. Also, measurements were made during 5–10 s and the walking speed was about 5–6 km/h (2 steps/s). The measurement frequency was 10 Hz instead of 4 Hz in our case.

Van Der Wegen-Franken et al.¹¹ have conducted a similar study on compression stockings. The SSI and DSI have been found to be similar. In that study, the interface pressure was not measured directly. The variation of leg circumferences was first measured and then the interface pressure was assessed, thanks to a leg-segment model with an air generator creating a pressure pattern to equalize the leg circumference. Moreover, the measurement frequency was 1 Hz.

In our case, the measurement probe remained in the same place all through the testing, and the pressure was measured directly under the compression system considering bandage system behavior. This might explain the differences in the results. The study we carried out has no bias due to a change in the position of the sensor during the test. Pressure was measured directly between the compression system and the skin.

Gradient pressure loss

Concerning the graduated pressure loss on the leg which is the operating principle of compression stocking, with the exertion of high pressure on the ankle and a graduated reduction along the leg up toward the thigh, we observed a consistent loss with B16, B17, and PK in all conditions but only in the standing position for RK. The studies of both Rimaud et al.⁴ and Chassagne et al.⁷ measured similar pressure losses on compression bandages.

For B16 and B17, the graduated pressure loss is basically accounted for by an increase in the bend radius of the leg, which is being subjected to constant tension. In the case of the PK, the first two bandages were applied without being extended and therefore without tension. The next two were elasticized bandages, applied while being extended and therefore under constant pressure. For the RK bandage, extension during application was difficult, in addition to which it had a tendency to slide and become rather distorted. To minimize these problems, the tension was usually greater near the calf during application.

All of these results show the working principle of compression systems from a different perspective. Walking combined with compression is frequently recommended in the treatment of venous pathologies. Elastic and inelastic bandage pressure range measurements during walking showed no major differences between the two types. On that basis, it appears that combining an adequate pressure level with walking^30,31 is the key to treating venous pathologies, rather than pressure variation as such.

Limitations

Pressure measurement was performed only at 3 km/h walking speed, and the tests lasted only for 1 h. As compression bandages are usually worn for 8 h, and sometimes more (up to 1 week, depending on the manufacturer recommendations), it would have been interesting to confirm the results obtained with a longer wearing time.

Moreover, the measurements have been performed on healthy participants. Conducting a similar clinical trial on patients suffering a venous oedema, may lead to other results.

Finally, even if the results are in line with the conclusions of Stick et al.,^23–25 it would be useful to confirm the variation of the volume of the legs with newer techniques, including optical ones.

Conclusion

This study demonstrates that compression bandages can be classified into two categories depending on the pressure variation exerted at the gaiter area, when the person is changing position from supine to standing.

Elastic compression bandages exhibit a low SSI while inelastic bandages and multi-layer compression systems exhibit a high SSI.

During walking, the pressure variation is much less than when moving from a supine to a standing position. Therefore, the DSI is not equal to the SSI whatever the type of compression bandages: elastic, inelastic, or multilayer system.

This study has also demonstrated that pressure loss is higher for inelastic bandages than for elastic bandages and multi-layer systems. Our measurements show that there is gradient pressure loss from the ankle to the calf for elastic bandages and multi-layer system, as is the case for compression stockings.

These findings suggest that the efficacy of compression bandages might not rely on pressure variation during walking only. It might rely on a sufficient interface pressure, but also on the activation of blood circulation thanks to the calf muscle and foot pump activation. Further research studies are needed to better understand the relationship between the level of compression, physical exercises (such as walking), and the efficacy of compression bandages.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Reynald Convert

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