Introduction

STRIDE, which stands for shape, texture, refill, issues, dosage, and etiology, provides a comprehensive guide for selecting compression garments and wraps. It is a resource for new clinicians and an excellent review for advanced practitioners. At WoundCon Fall 2022, Suzie Ehmann, DPT, PhD(c), CWS, CLT-LANA presented STRIDE in 2 parts. Part 1 of the STRIDE series reviewed physiological and methodological factors influencing the effect of compression garments. Part 2 of the STRIDE series explored edema assessment, and patient needs to best match the clinical presentation with an appropriate compression product. These sessions provided practical tips on how and what to evaluate in patients with edema, along with how to choose the best compression option to improve wound healing and enhance outcomes. Below, Dr. Ehmann addresses some of the questions viewers asked during the presentations based on her experience.

1. What does STRIDE stand for?

   This acronym stands for S (Shape), T (texture), R(refill), I(Issues), D(Dosage), and E (Etiology). Each letter of the acronym references a component that impacts compression selection.

2. What is “refill” in the context of STRIDE?

   REFILL references the dynamic nature of the edema relative to how it changes throughout the day when compression is in place and when it is removed. For example, let’s say that a patient states that their swelling goes down at night when they are sleeping. In this instance, they would not need a nighttime garment. On the other hand, if a patient states that their extremity swells when compression is removed, regardless of position or activity of the limb, this person would need compression for both day and night.

3. What are your thoughts regarding frail patients who can only tolerate light compression with a tubular compression sleeve (even overnight)?

   You are never wrong to start light and work your way up. Keep in mind that not all elastic tubular compression stockinettes are the same. An example would be the longitudinal elastic stockinette compared to the traditional stockinette. Both are 8-12mmHg, but the distribution of the compression across the limb (as the longitudinal stockinette covers only 20% of the tissue, 80% is not compression) can often provide better edema reduction because of the unique distribution of the compression. Additionally, don't forget about treating the coexisting comorbidities contributing to the edematous condition.

4. Would the stiffness also change depending on how tight the patient wraps adjustable wraps?

   No. Increasing the tension of a wrap only increases the dosage (or resting pressure). Increased dosage does not increase stiffness because they are different measurements. Stiffness references the textile’s resistance to stretch (higher stiffness is less elastic and means better containment). Simply applying the wrap with greater tension only increases dosage, which can be damaging. Now, if an adjustable wrap is not managing a patient’s swelling, my first thought would be to make sure that the patient is using the wrap appropriately. Ensuring appropriate use can be achieved by assessing and providing constructive feedback to patients when they come into the clinic relative to how the garment has been applied. For instance, is it appropriately placed on the limb? Are the straps appropriately applied/layered? For those devices with pressure markings, has the patient appropriately applied? For those garments without pressure markings, over the counter pressure meters can be used to instruct the patient.

5. I'm also curious about what we should look at when it comes to adjustable wraps. Does this mean we should value stiffness over dosage?

   This topic is not black or white because it is not one or the other. Rather, both dosage and stiffness are important. My point in highlighting stiffness in the presentation was to help clinicians understand the compression science beyond dosage, beyond resting pressure. For too long, dosage has been the sole prescriptive factor upon which compression science has been based. Focusing compression on dosage, a static number, negates the true power of a compression application, which is the working pressure. The working pressure is directly related to the resistance to stretch. It is this pressure dynamic that produces the “micro-massage” effect to stimulate a positive impact on lymphatic, venous, and arterial circulation.

6. What complications can occur if we focus solely on stiffness?

   When we want to optimize compression, finding that “sweet spot” where dosage, stiffness, pressure distribution, and patient comfort converge is necessary. This “sweet spot” will not be the same for every patient. For example, let’s say you have 2 patients, both with chronic venous insufficiency (CVI) and a venous leg ulcer (VLU). One patient is a middle-aged, ambulatory male who is tall and obese with significant lipodermatosclerosis and whose ankle circumference is 35cm. The other patient is an elderly female who is minimally ambulatory, petite, slightly overweight, with mild hyperkeratosis, and whose ankle circumference is 24cm. The dosage necessary to heal the wound for each of these patients is slightly different. The former patient will most likely need both higher resting pressure (dosage) and stiffness to achieve therapeutic hemodynamic response. Understanding compression beyond the dosage listed on a box can allow a clinician the ability to justify product selection between compression applications. The STRIDE compression selection algorithm highlights both unique aspects of compression textiles as well as patient specific characteristics that need to be considered when making a compression recommendation.

7. Why are flat knit stockings for daytime use only?

   I find manufacturers advise flat knit stockings only for daytime use. Any compression applications (flat knit or elastic knit) have the potential to gather or slide down, which could create a localized area of increased pressure, possibly leading to skin trauma.

8. What do you do to advocate for products that are not on the formulary of your organization?

   Don’t let someone else decide for you as to what is best for your patient. First, educate yourself. Read the literature to stay up to date on the latest research. Question the manufacturers regarding what research is available to define the efficacy of their product. Often product formulary changes are made by individuals who may not have insight into the clinical effectiveness of a specific product. Rather, products may be chosen based on which company offers the best price. When these scenarios occur, bring it to the attention of the value analysis committees, providing them with the research and specific patient scenarios demonstrating the unacceptable outcomes. You may not win every battle, but if you don't stand up for your patients, no one else will. You can also explore other avenues for getting your patients supplies, either through other billers who do carry the products that you think would work better for your patient. The old saying, “the squeaky wheel gets the oil," could be rephrased as, “the wound care clinician who demands individualized care for his/her patient has the best outcomes.”

9. Do you always conduct an ankle brachial index (ABI) prior to placing?

   It depends on the patient’s presentation and the other coexisting comorbidities. For example, let’s say that a 35-year-old female is referred for a garment fitting. The patient has a diagnosis of primary lymphedema, which was diagnosed at age 13, and she has no other past medical history. In this case, I will not conduct an ABI prior to fitting the patient because there is nothing in her history of present illness or clinical presentation that raises any red flags regarding her vascular state. However, for instance, let’s take a patient who is a 68-year-old male presenting with a non-healing venous leg ulcer who also relates a history of significant coronary artery disease (CAD), having suffered a myocardial infarction (MI) 3 months previously. He also smokes 2 packs of cigarettes per day and sleeps in a chair because, when he elevates his leg in the bed, his leg hurts him more. In this instance, I would conduct an ABI before I fit him for compression or before I put him into a compression bandage.

10. I’ve read that tensile strength decreases dramatically after just 24 hours for most 2-layer wraps. Are you seeing an increase in the frequency of compression wrap changes due to this finding?

    The idea of loss of both dosage (resting pressure) and working pressure over a period of wear needs even more research. Compression textile fatigue is real and is different for each compression application. However, it can also vary by patient and by patient presentation. This rationale is why it is crucial to match the compression textile and frequency of care to the individual patient presentation. Just because a bandage can be left on for a week doesn't mean it should or needs to be. My treatment practice is to see patients a minimum of 2 times per week. I will see them more frequently if there are excessive volume changes.

11. Please walk us through prescribing light circular compression from measurement to the choice of manufacturer.

    That is a tough one, as there are many options. I recommend reaching out to the compression manufacturers that service your area. Each major compression manufacturer offers a continuum of compression and would love to detail the specifics of their product lines that you have access to in your location.

12. Would you recommend routinely prescribing circular knit garments for patients who present with early secondary lymphedema (post mastectomy) stage 0?

    The literature for prophylactic compression garment fitting to “prevent” lymphedema following breast cancer treatment has not been defined. For this reason, I do not routinely “prescribe” compression to patients with no signs or symptoms of lymphedema. I do educate them about signs and symptoms. I also encourage screening programs that use advanced imaging to identify lymphatic impairment beyond circumference change. The one exception to this process is patients who will be traveling on long flights. In that case, I would fit them with a light compression sleeve and have them wear it daily for several weeks prior to the flight to assess the patient’s tolerance for compression.

13. I have a bariatric patient who has tried lymphedema wraps, 2-,3-, and 4-layer wraps, tubular compression, and elastic wraps. Each time we start her compression therapy, nothing seems to work.

    I have heard this problem before—actually, a lot. My response is generally that perhaps it is not the compression but the patient who is the problem. Hear me out! Far too often, when I follow up on cases like this example, it becomes apparent that the patient is expecting the compression garment to fix all their problems. Effective edema management is about not only finding appropriate compression selection and application but also identifying all coexisting comorbidities and addressing those as well. You could pick the most appropriate garment and apply the perfect bandage, and it won’t work if you don’t manage the underlying etiology. We must educate our patients to let them know that they are an active part of their treatment. A compression garment is only one piece of the puzzle.

14. Is there a cut-off number for applying compression? For example, if an ABI of 1.35 is greater than the normal value. Is compression contraindicated?

    ABI is one piece of the puzzle. It would be best to look at the coexisting comorbidities and clinical presentation. You must also match the compression to the patient as a whole person, not just focusing on a single number.

15. Can the STRIDE document and the demystifying document be included as an attachment, or could you give the website?

    STRIDE Professional Guide to Compression Garment Selection for the Lower Extremity

Conclusion

If you missed Dr. Ehmann’s talks at WoundCon Fall 2022, you can access them here on WoundSource Academy. During her sessions, Dr. Ehmann stressed that compression therapy is just one “piece of the puzzle” when it comes to treating patients with edema. Wound care professionals should consider all facets that contribute and can do so through the STRIDE mnemonic.

Suzie Ehmann, DPT, PhD(c), CWS, CLT-LANA is a consultant for 3M, Compression Dynamics, Medline Industries, Inc., Miliken, and Urgo. Dr. Ehmann is also Grant/Research support and on the Speaker’s Bureau for 3M, Compression Dynamics, Jobst, L&R, Medline Industries, Miliken, and Urgo. She is on the Advisory Board for Urgo.