Veins and Lymphatics 2014; volume 3:2107

[Veins and Lymphatics 2014; 3:2107] [page 29]

In vitro measurements of compression bandages and bandage systems: a review of existing methodsand recommendations for improvementJan SchurenRetired from 3M Deutschland GmbH,Skin and Wound Care Division, Neuss,Germany

Abstract

In this article an overview is presented ofidentified devices that are or can be used forin vitro pressure and stiffness measurementsof compression bandages and bandage sys-tems. The performance of these devices hasbeen evaluated on several parameters as wellas the clinical relevance of the findings. Inaddition, recommendations for improvementand standardization of future measurementsfrom the International Compression Club(ICC) working group compression bandagesare presented.

Introduction

There is a variety of methods to describe theproperties of bandages used for a variety of indi-cations where compression therapy is required.Often the extensibility of materials is used todetermine their characteristics. The GermanDIN quality standard (Deutsches Institut fürNormung EV)1 defines the elasticity of bandag-es by percent elongation following the applica-tion of a force of 10 N per cm bandage width.The resulting maximal stretch percentagedivides bandages in three categories: i) rigid(0-10%); ii) short stretch (10-100%); and iii)long stretch (>100%). Veraart et al.2 presentfour categories: i) non-elastic; ii) short-stretch(<70% maximal tension); iii) medium stretch(70-140%); and iv) fully elastic (>140%).Thomas3 classifies bandages into three distincttypes which have fairly precise clinical indica-tions. They are retention (class 1), light support(class 2) and the provision of varying degrees ofcompression (classes 3a-3d). These compres-sion bandages are subdivided into four groupsaccording to their ability to retain predeter-mined levels of tension under controlled labora-tory conditions. It is this tension which governsthe pressure that the various products might beexpected to apply in use. Thomas also recog-nizes that there are certain other highly special-

ized products available which may not fit intothis classification and these should therefore beconsidered separately.The International Compression Club (ICC;

http://www.icc-compressionclub.com/) held aconsensus meeting in 2005 on measurementsof lower leg compression in vivo and publishedtheir recommendations, in which was statedthat sub-bandage pressures and material stiff-ness characterize the elastic properties of theused materials and are the deciding parame-ters determining the dosage of compressiontreatment.4 Partsch describes the method tomeasure the pressure at a defined position ofthe lower leg at rest and to repeat the measure-ment on the same spot, when the circumfer-ence has maximally increased by the musclesactively engaged to stand in the upright posi-tion. The pressure in the supine position issubtracted from the pressure in stance. Theresulting index indicates the effectiveness ofthe applied system. This index is referred to asstatic stiffness index (SSI) and provides anindication of how well an applied compressionsystem manages to keep forces produced bythe muscle activity to stay in the upright posi-tion, inside the compressed area.5 Providedthat they are applied with the same restingpressure, typically short stretch bandages havehigher SSI’s than long stretch bandages.Following a subsequent ICC meeting, anoth-

er consensus document was published inwhich the growing trend is mentioned for theuse of both multilayer bandages and bandagekits that consist of several bandaging materi-als, which influence sub-bandage pressure andstiffness. It is stated that it is not possible touse in vitro data to predict the influence ofthese parameters and therefore they need tobe measured on the leg.6 Mosti et al. state thatthe physical characteristics of bandage kits, inwhich different materials are combined, can-not be predicted by laboratory tests and canonly be assessed in vivo by measuring theinterface pressure and calculation of stiff-ness.7 Schuren et al. conclude that althoughthe well-established SSI in general is able todifferentiate between elastic and inelasticmaterials, it only provides a rough estimate ofthe effectiveness of applied systems as inter-pretation is heavily influenced by the muscleforces of the person being bandaged.8

Besides the mentioned variation caused byvariability from the human leg, which cannotbe standardized, there is the variation causedby the person applying the system. The appli-cation of bandage systems by experiencednurses to volunteers9 or on artificial legs10

shows a marked variation in applied pressure.The consequence is that making statementson the possible effectiveness of an appliedsystem, is difficult.Medical elastic compression stockings

(MECS) can be divided into different classes

based on pressure. However, pressure is notthe only parameter that differentiates onestocking from another. Just as for compressionbandages, the so-called stiffness factor, theelasticity coefficient or slope value of thestocking is another important parameter. Thisslope value is defined as the increase in pres-sure when the circumference of the stockingincreases by 1 cm. This slope value is deter-mined in the laboratory.11 Neumann states thatit is not sufficient to determine the compres-sion (class) of the MECS alone, also the stiff-ness or elasticity coefficient is of importancefor the final results of compression therapy. Heprovides objective criteria for prescribingMECS for venous diseases in phlebology.12

Currently many different bandage systemsare commercially available. They all includeinstructions for their most optimal use. It isobvious that with so many available compres-sion bandages and systems, there is a need tohave a method that exactly determines theproperties of an applied system and eventualmodifications.13 Two decades ago, McCollumidentified the need to ensure that prescribablebandages meet acceptable standards of manu-facture and specified performance in terms ofelasticity, elastic range, elastic modulus, and

Correspondence: Jan Schuren, Grotestraat 34,6067 BR Linne, The Netherlands.E-mail: jan.schuren@gmail.com

Key words: compression therapy, bandages, band-age systems, in vitro measurements, pressure,static stiffness index, strain index.

Conflicts of interest: JS is a retired 3M employeeand invented and co-developed the 3M Coban 2Layer compression systems.

Members of the International Compression Club(ICC) working group bandages who agreed withthis consensus document: Abel M. (Germany),Bender D. (USA), Besse B. (Germany), Bichel J.(Germany), Charles H. (UK), Convert R. (France),Damstra RJ. (The Netherlands), Hitschman G.(Germany), Kloeppels M. (Germany), Mooij M.(The Netherlands), Morrison T. (USA), Mosti G.(Italy), Muldoon J. (UK), Partsch H. (Austria),Planisek Rucigaj T. (Slovenia), Polpot S. (France),Schuren J. (The Netherlands), Schwidden I.(Germany), Will K. (Germany).

Received for publication: 5 November 2013.Revision received: 27 May 2014.Accepted for publication: 28 May 2014.

This work is licensed under a Creative CommonsAttribution 3.0 License (by-nc 3.0).

©Copyright J. Schuren, 2014Licensee PAGEPress, ItalyVeins and Lymphatics 2014; 3:2107doi:10.4081/vl.2014.2107

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durability and suggested to lay down these cri-teria and classify bandages according to somemeasure of elasticity and elastic modulus.14

Clark states that simplistic descriptions ofshort-stretch and long-stretch bandages fail totake account of the huge variations withinthese two groups and, more importantly, thedevelopment of multi-layer compression sys-tems that combine materials with differentperformance characteristics. He concludesthat the current classification system refers toindividual bandages and does not adequatelyreflect the physiological effects of multi-layerbandaging systems and that a European-widestandard for the testing and classification ofbandage systems is required.15

Schuren developed and validated a method tomeasure under completely controlled conditionsthe capabilities of an applied compression sys-tem to keep the forces inside the system, simi-lar to the SSI. As the name SSI is well estab-lished, a different description was needed forthe value from this measurement and the termstrain index was selected.13 In a recent docu-ment, Cornu-Thenard et al. propose that theterm resistance should be used in the medicalcompression vocabulary or that perhaps wordssimilar to resistance or resistance coefficientcould be used such as hardness, rigidity, firm-ness, inelasticity and others.16

As in vitro measurements can be performedover a longer period, also the effects of materi-al fatigue on pressure and stiffness can beinvestigated.In an overview to highlight the differences

between different compression materials,Clark states that if the main in vitro and invivo comparisons are to remain pressure andforce measurement bound, then there is aneed for a consistent classification systembased upon the pressure measurements tomirror the agreed consensus upon how sub-bandage pressures are to be measured.17

Figure 1 shows an overview of evaluationsthat can be performed on compression bandag-es and bandage systems, with the specific rolefor in vitro and in vivo research.In this article an overview is presented of

identified devices that are or can be used for invitro pressure and stiffness measurements ofcompression bandages and bandage systems.The performance of these devices has been eval-uated on several parameters as well as the clini-cal relevance of the findings. In addition, recom-mendations for improvement and standardiza-tion of future measurements from the ICC work-ing group compression bandages are presented.

Materials and Methods

A search in the medical literature was per-formed in the personal database (Papers

2.2.10; mekentosj.com) and using Medline.Next an extensive manual search was carriedout in the bibliographies of identified articles.The search was focused on identifying allavailable methods that could be used for invitro pressure and stiffness measurements ofcompression bandages and/or compressionbandage systems (JS). There were no restric-tions on quality of identified papers. Next, apatent search was performed using the UnitedStates Patent and Trademark Office(http://patft.uspto.gov) and the EuropeanPatent Office (www.epo.org) and identifiedpatents were downloaded (JS). A question-naire was developed with key questions on themethod and presented in Table 1.If the identified published information was

sufficient to answer these questions, the ques-tionnaire was completed (JS). If this was notthe case, the identified researchers were con-tacted with the request to provide additionalinformation or to complete the questionnaire.The search ended on May 1, 2013. The results

were presented at a meeting of the ICC work-ing group bandages in Copenhagen on May 18,2013 (JS) for further discussion.

Results

A total of seventeen devices were identified,nine of them were disclosed in the published lit-erature, six were found in patent applicationsand two were brought in by members of the ICCworking group bandages, who used them intheir commercial working environment. Theoldest identified device was disclosed in apatent application from 1979, the last camefrom a publication from 2012. An overview ofthe devices is listed on date of publication,either in literature or on date of patent applica-tion and is presented in Table 2.13,18-30 Severaldevices are published in more than one publica-tion; the one that describes the device in thehighest detail is listed in the overview.

Figure 1. Evaluation methods on compression bandages and bandage systems.

Table 1. Questionnaire with the key questions.

Name of the device: ..................................

Resting pressure (y/n): ............................................Stiffness (y/n): ............................................Application method automated (y/n): ............................................Validation available (y/n): ............................................Available for bandages (y/n): ............................................Available for bandage systems (y/n): ............................................Is the device ready to be used (y/n): ............................................Is the method disclosed (y/n): ............................................

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After completion of the questionnaires, thecollected information was transferred to asheet in which each yes from the question-naire was marked in green and each no in red.This sheet is presented in Figure 2.

Discussion

For compression bandages and bandagingsystems, there is a variety of methods to look attheir physical properties. Measuring pressureand stiffness are only a few and In this article,only a minor number of studies describingthem are referenced. The ICC has published aconsensus document on how the sub-bandagepressure can be measured4 and a document onthe classification of bandages.6 For a variety ofreasons, in vitro measurements have alsobeen widely used, not only for stockings butalso for bandages.For in vitro measurements of bandages and

bandage systems for compression therapy, it isimportant that not only the pressure can beidentified but also that information can be col-lected on the stiffness, a measure of the possi-ble performance. Ten of the seventeen identi-fied devices fulfill that requirement. Anotherimportant factor for in vitro measurements isthat the used method is completely controlledand therefore reproducible. This implies thatthe application must be automated. For most ofthe identified systems, bandages have to beapplied manually, which reduces the repro-ducibility. Six identified devices use variousautomated applications. Combining the posi-tives on stiffness and automated application,leaves only two devices with a green for bothparameters. One of them is still under design,which means that only one device (number 13,Figure 3) has a complete green scorecard.When bandages or systems are applied with

this winder, the force needed to bring eachindividual component to the required percent-age stretch, is calculated on a tensile tester(e.g. 50% for Profore layer 3; Smith & NephewCorp., London, UK). From this force, theweight is calculated with which each individ-ual component of a system must be stretchedwith the exact amount of tension. Water filledbottles are used of which the weight is con-trolled with 0.01 grams of precision on a cali-brated scale. As can be seen on Figure 3, pres-sure is measured with a PicoPress® [MicrolabElettronica SAS, Ponte S. Nicolò (PD), Italy]sensor and the data can be stored on a comput-er. The sensor is positioned on a fluid bag. Thestiffness of a system can be measured byinflating another sensor underneath the fluidbag with a controlled amount of air.An example of a pressure recording with the

above described roll winder is shown in theupper measurement in Figure 4.13,31

However, many other identified deviceshave unique design features that could eventu-ally be used to develop an optimal in vitromeasuring device. E.g., where device number16 from Figure 3 only uses the small area ofthe fluid bag to imitate muscle enlargement,the mannequin leg developed by Hirai et al.31

(device number 14, Figure 5), uses the entirearea of the leg to enlarge. This may have sev-eral advantages, of which probably the mostimportant that this total enlargement reflectsthe natural situation in a more realistic way.The ICC working group bandages discussed

the findings of the review in a meeting heldon May 18 2013 in Copenhagen. In this andtwo subsequent meetings held in Germany,the group agreed on a number of recommen-dations for in vitro measurements of com-

pression bandages and bandage systems.These recommendations are listed in Table 3.An overview of the discussed topics is provid-ed below.

Leg-shaped model or cylinder?An important question for in vitro meas-

urements of bandages and bandage systemsis if the model on which the measurementsare to be made, should have a leg-shape or ifit can be a cylinder. Twelve of the seventeenidentified devices use a leg model, of whichonly one allows an automated application.The advantage of a cylinder is that not onlyexactly the number of layers can be appliedthat is recommended by the manufacturer butalso the force of application can be evenly dis-tributed over the entire width of the roll. The

Table 2. An overview of the identified devices.

No. Name of device Disclosed in

1 Hosiery testing apparatus Swallow18

2 Measuring apparatus Wray et al.19

3 Hosiery pressure measuring device Pirlitescu et al.20

4 Pressure measuring device Testud et al.21

5 Cylindrical limb model Melhuish et al.22

6 Wooden leg Partsch et al.23

7 Mannequin leg Rajendran et al.24

8 Leg garment test apparatus Kuenzli et al.25

9 Mannequin leg Ghosh et al.26

10 Elastically deformable limb Wesp et al.27

11 Test rig Al Khaburi28

12 Mannequin leg Schuren13

13 Roll winder Schuren13

14 Mannequin leg Hirai et al.29

15 Air bladder mannequin leg Kumar et al.3016 Wrapping unit Not disclosed; concept of Karl Otto Braun GmbH & Co.

KG, Wolfstein, Germany17 Compression model leg Not disclosed; used by Lohmann & Rauscher GmbH & Co.

KG, Rengsdorf, Germany

Figure 2. The score card with the 17 devices; each green cell indicates a yes, each redcell a no.

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recommendation of the ICC working group isthat for in vitro testing of compression band-ages and bandage systems, cylinders shouldbe used. Concerning the material that cylin-ders are made of, the ICC working group rec-ommends that the friction between cylindersurface and bandaging material should bereduced to the minimal (e.g. by using pol-ished steel).

Application methodIf in vitro pressure measurements are per-

formed on leg-shaped models, it is difficult tohave an automated application. This is not asurprising result as most of the revieweddevices were developed to perform measure-ments on stockings and one to performresearch on the reproducibility of pressureand stiffness (device 12). The one leg modelwhich has an application that is described asautomatically (device 7), uses a manualwinder to turn the fixed leg.29 Although it ispossible with this device to apply bandageswith e.g. a 50% overlap, it is difficult to havethe forces distributed evenly because of theirregularly shaped leg. The recommendationof the ICC working group is that for in vitrotesting of compression bandages and bandagesystems, the application should be performedas recommended in the instructions for use.In addition, it is recommended that applica-tions should be controlled, automated andreproducible.

StiffnessAs mentioned, an in vitro assessment of

stiffness of compression bandages and espe-cially of bandage systems, the model needs acontrolled and reproducible method to imitatethe real life situation of measuring the SSI, thedifference between the pressure in the supineand upright position. To achieve this enlarge-ment, the mannequin leg (device 14) is cut inhalf lengthwise and when the lever arm ispushed down, the leg splits by 0.5 cm, leadingto a 1 cm increase in circumference. Thismethod of enlargement guarantees an easyand reproducible method. An example of apressure recording with the above describedmannequin leg is shown in the lower measure-ment in Figure 3. Ten of the seventeen devicesallow stiffness recordings and use differentmethods of enlargement to achieve thesemeasurements. An increase of 1 cm over theentire area used in four of them (devices 14,15, 16 and 17). Stolk et al. measured the max-imum difference between the maximal dorsi-flexion and maximal plantar flexion circumfer-ence at the point where the gastrocnemiusmuscle passes over into its aponeurosis (theso-called B1 point) in five volunteers andfound a mean difference of 1.18 cm.32

Enlarging with 1 cm is arbitrary but based onthe findings of Stolk et al., a value that reflects

a real-life situation. A 1 cm increase in circum-ference also correlates with the stiffnessmeasurements of elastic stockings, which isdefined by the European Committee forStandardization (CEN) as the increase in pres-sure per 1 cm increase in leg circumference.33

The recommendation of the ICC working groupis that for in vitro testing of compression band-ages and bandage systems, stiffness measure-ments should be in line with existing methods

like the CEN method. As mentioned in theintroduction, the name SSI is well establishedand recommended to be used for in vivo meas-urements.4,5 The recommendation of the ICCworking group is that stiffness measured invitro should not be named static stiffness index.For stockings, the term dynamic index is used.For bandages and bandage systems, a newterm e.g. strain index8,13 or in vitro statical stiff-ness index could be introduced.

Figure 3. The automated roll winder (device number 13).

Figure 4. In vitro pressure and stiffness recordings with device number 13 (upper line)and device 14 (lower line); the picture is composed with data from Schuren13 and Hiraiet al.,31 which in the original publications are presented on a different scale.

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Radius/circumference of thecylinderOn four of the seventeen identified devices

in this review, cylinders are used to performthe measurements. Following Laplace’s law,the final pressure of an application depends onthe tension with which the bandage is appliedas well as the radius of the cylinder to which itis applied. The six identified devices use dif-ferent radii with an average radius of 4.7 cm(range 4.0 to 6.1), which is an average circum-ference of 29.3 cm. Schuren used cylinderswith a radius of 4 and 5 cm (circumference25.1 and 31.4 cm). In the test method valida-tion, four different operators applied four dif-ferent compression systems on both cylin-ders.13 The test results reveal that the pres-sures on the cylinders with the radius of 5 cm,are close to the expected range of pressureswhen these systems are used in clinical prac-tice. However, further unpublished research ofone of the group members revealed that if themethod of enlargement described by Hirai etal.29,31 is used on cylinders, a diameter of 4 cmis closer to the expected range.34 Based onthese findings, the recommendation of the ICCworking group is that for in vitro testing ofcompression bandages and bandage systems,cylinders should be used with a radius of 4 cm(circumference 25.1 cm).

FatigueTo have an objective measurement of the

degree and duration of the compression exert-ed by six commonly used elastic bandages,Tenman et al. tested the sustainability of pres-sure on healthy volunteers.35 They found pres-sure drops up to 63% in 4 h. Partsch reportsthat when bandages with a high stiffness areapplied, a pressure drop will occur in the firstminutes and hours when the patient is walk-ing to values that are 30-40% lower comparedto the initial pressure. He states that this dropis mainly due to an immediate reduction of legvolume and that for the next few days only amild further pressure drop occurs.36 Providedthat an applied system stays in place, observedpressure drops may be caused by a combina-tion of edema reduction and material fatigue.When loss of pressure is measured on volun-teers, it is impossible to identify which of thetwo components contributes for which part. Byprofiling the pressure of compression bandag-es by a computerized instrument, Das et al.showed that in bandages with higher mass perunit area, the internal pressure applied by thebandage decreases at a higher rate than inbandages with lower mass per unit are. Inaddition, the authors showed that the internalpressure profile with time is different for dif-ferent bandages, higher internal pressures

show a higher rate of pressure loss over time.37

This implies that material fatigue and result-ing pressure loss could have an effect on pres-sure but also on stiffness and therefore on theeffectiveness of applied systems over time.Schuren studied material properties in vivo onhealthy volunteers and in vitro under con-trolled conditions (Figure 6), both over a one-week period and found significant differencesbetween these measurements. Isolating theeffect of material fatigue on pressure and stiff-ness revealed that most of the pressure losstakes place in the first four hours and thatafter 48 h, the pressure stays stable for thematerials under investigation.13

In vitro measurements allow pressurerecordings over a longer period and in differ-ent ways. Figure 6 shows that recordings canbe taken at different intervals and in Figure7,38 the recordings are presented of measure-ments during constant motion to mimic awalking pattern.Therefore the recommendation of the ICC

working group is that for in vitro testing of com-pression bandages and bandage systems, meas-urements are performed at specific intervalsover a specific period, or e.g. to mimic a walkingpattern over a certain period. As material fatiguestarts immediately after the application and isfurther enforced by stiffness measurements, it

Figure 5. The mannequin lag with the leverarm, which when pushed down, guaranteesa 1 cm enlargement in circumference(device number 14).

Table 3. Recommendations of the International Compression Club working group band-ages for in vitro measurements of compression bandages and bandage systems.

Topic Recommendations

Leg-shaped or cylinder It is recommended that measurements are performed on cylinders.It is recommended that the friction between cylinder surface and bandagingmaterial should be reduced to the minimal (e.g. by using polished steel).

Application method It is recommended that applications are performed as recommended in theinstructions for use.It is recommended that applications should be controlled, automated andreproducible.

Stiffness It is recommended that stiffness measurements should be in line withexisting methods like the CEN method.It is recommended that stiffness measured in vitro should not be namedstatic stiffness index; the term dynamic index used for stockings could beused or a new term like strain index could be introduced.

Radius/circumference It is recommended that for in vitro testing of compression bandages and of the cylinder bandage systems, cylinders should be used with a radius of 4 cm

(circumference 25.1 cm).Fatigue It is recommended that measurements are performed at specific intervals

over a specific period or e.g. to mimic a walking pattern over a certain period.As material fatigue starts immediately after the application and is furtherenforced by stiffness measurements, it is recommended to first perform themeasurement of pressure under tension before measuring the pressure inthe relaxed position.

Pressure sensor It is recommended that for in vitro testing of compression bandages andbandage systems, pressure should be recorded with a PicoPress® transducer(Microlab).It is recommended to perform further research on the reproducibility of thePicoPress® (Microlab) device or alternative methods.

CEN, European Committee for Standardization.

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is also recommended to first perform the meas-urement of pressure under tension before meas-uring the pressure in the relaxed position.

Pressure transducerIn an ICC consensus document with recom-

mendations for in vivo measurements, anoverview is presented of key specifications of apressure sensor.4 Partsch et al. compared threeportable instruments and conclude that the bestreproducibility and the highest degree of accu-racy was achieved with the PicoPress® trans-ducer (Microlab), which in addition also allowsdynamic pressure tracing in connection with asoftware program and which may be left undera bandage for several days, is a reliable instru-ment for measuring the pressure under a com-pression device.39 Al Khaburi reviewed availabletypes of pressure measurement transducers tomeasure the interface pressure under compres-sion products and states that these transducersdiffer in their core technology, physical dimen-sions, accuracy and their ability to provide

dynamic measurements. He identified a total ofmore than thirty types that could be used. Heperformed a comprehensive analysis on differ-ent pressure transducers among which thePicoPress® transducer (Microlab). One of theconclusions is that the PicoPress® (Microlab)sensor was found to have good accuracy interms of low nonlinearity, and hysteresis errorsbut that it overestimates the pressure applied toit due to its physical dimensions. The usage of acorrection factor for the pressures measured byPicoPress® (Microlab) sensors could improvethe reliability of their pressure readings.However, the author states that correction fac-tors are calculated from the radius of curvatureof the leg which is very difficult to determinewithin a clinical environment.28 As the recom-mended in vitro measurements in this articleare performed on cylinders with the sameradius, an accurate, reliable and repeatableoverestimation does not play a major role andthe suggested correction is not required. Basedon these findings, the ICC working group rec-

ommends that for in vitro testing of compres-sion bandages and bandage systems, pressureshould be recorded with a PicoPress® transduc-er (Microlab). Because of the reported overesti-mation of the pressure, it is recommended toperform further research on the reproducibilityof the PicoPress® (Microlab) device or alterna-tive methods.

Next stepsAfter the ICC working group bandages meet-

ing in Copenhagen, a few members agreed toimplement the recommendations to furtheroptimize the in vitro measurement of com-pression bandages and bandaging systems.This work is still ongoing. In addition, the ICCworking group bandages agreed to performfurther research to investigate the relationbetween in vivo and in vitro measurements.

RecommendationsRecommendations of the ICC working group

bandages for in vitro measurements of com-pression bandages and bandage systems aresummarized in Table 3.

Clinical relevanceIn vitro measurements of pressure and stiff-

ness is a well known method used for the clas-sification of medical elastic compression stock-ings. There are several classification systems indifferent part of the world, which have one thingin common, they are all based on the findings ofin vitro measurements.11 For bandages or band-age systems that are used for compression ther-apy, there is no common language to describethe physical properties. There is only one classi-fication system for bandages, which is based onforce-elongation curves obtained in a laborato-ry.6,40 This system only provides pressure infor-mation on bandages used for so-called singlecomponent applications and uses light (<20mmHg), medium (21-30 mmHg), high (31-40mmHg) and extra high (41-60 mmHg) as pres-sure ranges. For single component bandages,the terms rigid or no-stretch (0-10%), short-stretch (10-100%) or long-stretch (>100%) aremost often used. These definitions are based onthe percent elongation of the material afterapplication of a force of 10 N per cm bandagewidth.1,6 Veraart et al.2 and Thomas3 alsodescribed classification systems for single com-ponent compression bandages. However, manybandaging systems are commercially availablefor which these terms are not very useful. Mostof the used materials have package inserts todescribe how they are best used. A validated andreproducible method to investigate the pre-ferred application method is not available yet. Itis obvious that a standard for testing and classi-fication of bandage systems is required.15 In anearlier ICC consensus document, the practicalaspects of classifying compression bandages

Figure 6. Measurement of pressure (in mmHg) and strain index over a longer period.

Figure 7. Measurement of pressure (in mmHg) during motion mimicking a walking pat-tern. Modified with permission from Steinlechner and Bernat.38

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was presented.6 One of the conclusions was thatfuture descriptions of compression bandagesshould include the sub-bandage pressure rangeas well as information on the stiffness of thefinal bandage. The development of a validatedclassification system is one of the objectives ofthe ICC working group bandages. This docu-ment presents the current status, recommenda-tions and next steps of the development of thesefuture descriptions. With such a descriptive sys-tem in place, specific information on the physi-cal properties of bandages and bandaging sys-tems can be provided on packaging and instruc-tions for use, similar to the ones used for com-pression hosiery.

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