Introduction
Despite its proven effectiveness in managing venous and lymphatic disorders [1], compression therapy often fails due to poor patient adherence, the leading cause of treatment failure and recurrence. It remains the gold standard for treating chronic venous insufficiency (e.g., stasis dermatitis, venous ulcers) and a cornerstone of lymphedema management [2-4]. However, adherence is frequently compromised by discomfort, difficulty in application, and limited understanding of its necessity [5].
Patients requiring compression therapy typically present with lower limb edema, skin changes, or ulceration resulting from venous insufficiency or lymphatic disorders. These conditions frequently require prolonged management with compression devices, making long-term adherence essential for successful outcomes [6,7]. To address these challenges, the author designed a multifaceted educational protocol applicable to both inpatient and outpatient settings. Unlike conventional approaches, which often rely on information provision, this approach integrates: (1) improving targeted health literacy; (2) providing a structured demonstration-observation-performance-feedback model for hands-on bandage compression training; and (3) incorporating a pivotal caregiver-centered education component designed to help patients cope with physical limitations in self-application. With selected cases, this report presents the educational protocol and its application in clinical practice. The report was approved by the Institutional Review Board (IRB No. CR-23-134). The patients provided written informed consent for the publication of their images for educational and research purposes.
Idea
Education protocols
This compression therapy education protocol aimed to improve patient adherence and enhance patient self-management and caregiver-assisted management in individuals with chronic venous insufficiency or lymphedema requiring compression therapy. It comprised two interconnected phases applicable in both inpatient and outpatient settings, emphasizing active patient/caregiver participation. Caregiver education was provided concurrently, with patient consent, due to the difficulty patients had in self-applying elastic bandages (Fig. 1).
Initial education and patient perception modification phase
During hospitalization or initial outpatient visits, in addition to ongoing treatment and wound care, patients and caregivers received education in four stages.
Stage 1: information on disease and compression therapy
Provided information on pathophysiology, skin lesion progression, and compression therapy mechanisms, including improved blood flow, edema reduction, and valve support. The treatment goals of symptom relief, lesion improvement, and recurrence prevention were explained along with the importance of continuous application. Understanding was confirmed, and questions were addressed. The expected therapeutic effects on symptoms were outlined.
Stage 2: explanation of elastic bandages and materials
Characteristics of the 4-inch elastic bandage (even pressure, potential increase in tension, texture) were explained. Skin preparation (cleansing, drying, and protectant application) was demonstrated. The use of adhesive tape instead of metal clips for securing bandages was advised.
Stage 3: demonstration of elastic bandage application
The process was demonstrated on the affected area over a foam dressing, starting from the foot with 50% overlap and 50% stretch to generate up to 40 mmHg of pressure. A method for verifying adequacy of pressure by inserting a finger beneath the bandage was shown, checking for moderate resistance without excessive tightness, and the caregiver practiced this technique to ensure the appropriate degrees of compression were achieved [1,8].
Stage 4: education on managing adverse signs
Observational points for excessive compression (increased pain, skin color changes) and management strategies were instructed. Adjunctive self-management (calf exercise, leg elevation) was advised.
The day after demonstration, during dressing changes, clinical improvements (reduced edema/induration) were observed and described to the patient/caregiver, reinforcing understanding and commitment to home treatment.
Post-discharge/outpatient follow-up phase: caregiver-led management and monitoring
Caregivers were instructed to apply the elastic bandage daily at home after wound care. At the first outpatient visit (within 7 days post-discharge), with the bandage applied by the caregiver, its appropriateness was evaluated. After removal, wound/skin improvement was assessed, and feedback was provided to improve understanding and confidence for continued home therapy. The following two representative cases illustrate the practical application and effectiveness of the educational protocol. Both cases present how the structured educational intervention successfully addressed previous adherence issues and led to improved clinical outcomes.
Case 1
A 65-year-old woman with a history of lymphedema-related recurrent swelling on her right leg, erythema, and unsuccessful use of compression stockings, was admitted for sepsis. Lymphoscintigraphy confirmed impaired lymphatic drainage; Doppler/computed tomography ruled out deep vein thrombosis. She presented with fever, chills, and a 10×10 cm black blister on the right foot dorsum. C-reactive protein (CRP) levels were measured at 259.4 mg/L; blood cultures grew Streptococcus dysgalactiae. After initial sepsis management and wound referral (Fig. 2A), the education protocol was initiated with the patient and her daughter, the caregiver. Following exudate control with initial povidone-iodine soaking dressings, foam dressings and compression bandaging began. Stages 1-4 were demonstrated on day 1; daily sessions of Stage 2-4 followed, with the daughter practicing pressure checks (Stage 3). One week later, the patient’s CRP levels decreased to 4.8 mg/L, and the patient was discharged. Two weeks post-discharge, the daughter effectively managed care, reducing exudate/swelling (Fig. 2B). At 3 months, the wound healed, edema subsided sufficiently for compression stockings (Fig. 2C), and the patient began regular complete decongestive therapy. No re-hospitalizations related to these symptoms were necessary during the subsequent 2 years.
Case 2
A 61-year-old woman with a history of discomfort and non-adherence to prescribed compression stockings for recurrent right lower leg swelling and erythema presented with fever and widespread exudate. Lab findings displayed elevated CRP (47.8 mg/L) and white blood cell (9,700/μL) counts. Color duplex Doppler showed patent arteries and veins but dilated right calf veins (Fig. 3A); computed tomography showed diffuse subcutaneous edema (Fig. 3B) but no deep vein thrombosis or abscess. The patient was admitted for infection and referred to wound care for ruptured blisters (Fig. 3C). Given her history of non-adherence, elastic bandages were introduced as an easier alternative. Stage 1 of the education protocol was provided to the patient and her son, the caregiver, on the first day. After wound care, compression was applied, with instructions for immediate removal if adverse symptoms were observed. Redness and previously copious exudate decreased by the next day. Daily sessions of Stage 2-4 were conducted. During daily Stage 3 education, the son actively practiced pressure checks and was taught to reapply the bandage if necessary. The son expressed confidence in applying bandages, and the patient was discharged. Ten days later, CRP levels normalized to 2.7 mg/L with wound improvement (Fig. 3D). After another 10 days, the patient was fully recovered (Fig. 3E). She transitioned to compression stockings successfully and has remained recurrence-free.
Discussion
Caregiver involvement is essential in chronic disease management, with caregivers often acting as advocates and aiding adherence [9,10]. Both chronic venous insufficiency and lymphedema require ongoing management, underscoring the need for caregiver education in compression therapy application and monitoring [3,9]. Comprehensive patient assessment is essential before initiating compression therapy. Measuring the ankle-brachial index (ABI) helps identify arterial insufficiency, which may contraindicate compression or require adjustment of its intensity [2,6,11,12]. This evaluation is a key component of the protocol’s safety measures. However, while the ABI is generally a reliable screening tool, caution is warranted for diabetic patients, especially those with neuropathy or chronic kidney disease, as medial arterial calcification—common in these populations—can lead to falsely elevated readings [13].
Poor adherence to compression therapy is multifactorial, stemming from pain and/or discomfort, psychosocial issues, insufficient health literacy, physical limitations, financial burden, and lifestyle constraints [5,7]. The education process in this study aimed to address these by: (1) using foam dressings to reduce pain and skin problems; (2) motivating patients and caregivers by demonstrating therapeutic effects, building trust, and explaining the necessity of sustained wearing to prevent recurrence; (3) improving health literacy; (4) helping patients cope with their physical limitations through caregiver education; (5) initially using cost-effective elastic bandages for acute care, and suggesting a later transition to compression stockings for long-term management, thereby reducing immediate financial burdens; and (6) aiming for a quicker return to stockings by effectively reducing edema and healing wounds.
Both case patients in this report had histories of repeated hospitalizations and prior non-adherence to compression stockings due to discomfort, leading to worsened edema and ill-fitting garments. The educational process provided to these patients and their caregivers is believed to have increased motivation, ensured appropriate application, allowed experience of positive effects, and thus increased adherence. The protocol was applied to eight patients requiring compression therapy, with no subsequent repeated hospitalizations observed. This report detailed the educational process and outcomes in two of these cases. However, the limited number of cases restricts the extent to which the findings can be generalized. Further research evaluating outcomes in larger populations is required. Nevertheless, the protocol is expected to serve as a basis for developing future compression therapy education programs.
In conclusion, the compression therapy education protocol described in this study offers a structured approach to improving patient adherence by addressing multiple barriers through targeted interventions. Integrating caregiver education, practical skills training, and continuous reinforcement provides a comprehensive solution to the common challenges associated with compression therapy. Although further research with larger patient population cohorts is required to validate these findings, this protocol represents a promising framework that can be adapted across various healthcare settings. Improving adherence to compression therapy can enhance wound healing outcomes, reduce recurrence rates, and ultimately improve patients’ quality of life while decreasing healthcare utilization costs associated with complications of chronic venous and lymphatic disorders [6,7,14].
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