Systematic Review: Graduated Compression Stockings to Prevent DVT

This report is a systematic review investigating the impact of graduated compression stockings (GCS) on preventing deep vein thrombosis (DVT) in post-operative orthopaedic patients. A literature search was conducted using MEDLINE and CINAHL databases, focusing on studies related to GCS, DVT, and postoperative care. Four relevant articles were critically analyzed, revealing that while GCS may reduce DVT risks initially, the difference between GCS and standard therapy lacked significant statistical support. The review discusses the mechanism of action of GCS, its clinical implications, and highlights the need for multicenter randomized trials to confirm its effectiveness across broader populations. The study concludes that clinicians can consider GCS for DVT risk reduction in orthopaedic patients, but further research is necessary to validate these findings.

Running head: SYSTEMATIC REVIEW
What is the impact of graduated compression stockings to prevent DVT in post-operative
orthopaedic patients?
Name of the Student
Name of the University
Author Note

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Abstract
Background- Patients undergoing orthopaedic surgery have the risk of being affected with
Deep Venous Thrombosis (DVT), marked by formation of blood clot in the deep veins that
are located in the lower extremities.
Aim- To determine the impact of graduated compression stockings (GCS) for preventing
DVT in post-operative orthopaedic patients
Method- Articles were extracted from MEDLINE and CINAHL electronic databases by
using search terms like, “graduated compression stockings”, “DVT”, “deep venous
thrombosis”, “postoperative”, “patients”, “impact”, and “effect”, which were combined with
boolean operators.
Results- 4 articles relevant to the research question were retrieved and critically analysed.
Although GCS was allied with reduced risks of DVT onset during the initial stages, there was
lack of significance in the difference between GCS and standard therapy.
Conclusion- Clinicians can administer GCS among orthopaedic patients for reducing their
likelihood of suffering from DVT. However, multicentre randomised trials need to be
conducted for confirming the impacts of the intervention on a wider population.
Keywords: orthopaedic, surgery, deep venous thrombosis, graduated compression stockings

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Table of Contents
Introduction................................................................................................................................4
Background................................................................................................................................4
Research question...................................................................................................................5
Research aim..........................................................................................................................6
Research objectives................................................................................................................6
Methodology..............................................................................................................................6
Search strategy.......................................................................................................................6
Selection criteria.....................................................................................................................6
Data collection and extraction................................................................................................7
Critical appraisal....................................................................................................................7
Results........................................................................................................................................7
Description of included studies..............................................................................................7
Outcomes of the included studies..........................................................................................9
Discussion................................................................................................................................10
Strength and Limitation........................................................................................................14
Clinical implications............................................................................................................14
Conclusion................................................................................................................................16
References................................................................................................................................18
Appendix..................................................................................................................................22
PRISMA chart......................................................................................................................22
Critical review of included articles......................................................................................23

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Data extraction.....................................................................................................................54
Excluded Articles.................................................................................................................61

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Introduction
Graduated compression stockings refer to distinct stockings that work with the aim of
promoting circulation in the legs. In the veins that are located in the legs, blood must
typically flow upwards, in the direction of the heart (Priego et al. 2015). In other words,
graduated compression stockings have been found effective in applying a precise amount of
pressure, at regions near the ankles, followed by gradual application of pressure, of
decreasing intensity, while moving up the legs. Hence, the primary benefit of graduated
compression stocking can be accredited to the fact that they facilitate squeezing or pushing
blood from the ankles to the thighs, with the effort of counteracting blood pooling in the leg,
and the swelling that ensues (Beliard et al. 2015). This assignment will focus on a systematic
review that will be based on a thematic analysis on the effects of graduated compression
stockings on DVT.
Background
Deep Venous Thrombosis (DVT) encompasses situations where blood clot formation
occurs in deep veins that are most commonly located in the legs. In other words, DVT occurs
when thrombus or blood clot develops in one or more than one of deep veins that are located
primarily in the legs (Van Gent et al. 2014). Irish doctors typically estimate that there roughly
4,000 deaths occur every year due to DVT and pulmonary embolism (PE), which combined
together result in Venous Thromboembolism (VTE). Of these death rates, 1,900 deaths have
also been recognised as avoidable through novel treatment options, and better management,
pooled with patient knowledge and awareness (Thrombosisireland.ie 2018). Time and again
it has been proved that prolonged bed rest due to increased length of hospitalisation makes
the legs of the patients remain still for a considerable period of time.

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This prevents contraction of the calf muscles, preventing proper blood circulation,
thus increasing chances of blood clots and DVT (Swanson 2015). DVT has also been
identified as one of the most feared complications that occur amid post-operative patients,
owing to the fact that the condition is related with sudden shortness in breath, light-
headedness, rapid pulse rate, and coughing up of blood, and substantial rates of mortality and
morbidity. Majority of patients who report the onset of postoperative DVT, are typically
asymptomatic. Compression therapy has been identified as a commonly used type of physical
therapy under clinical circumstances that involve lymphatic and venous insufficiency in the
lower limbs, in addition to varicosities, venous eczema and ulceration, lymphedema, DVT,
and post-thrombotic syndrome (Zarchi and Jemec 2014).
Lee et al. (2015) also stated that among chief lower limb surgeries, female gender,
and having undergone a knee replacement arthroplasty were the most easily identified risk
factors that led to the development of postoperative DVT. Results from their study also
indicated that relative risks of DVT was an estimated five times greater in patients who were
aged between 50-69 years and was also 10 times greater among patients who were aged more
than 70 years (p<0.001). On the other hand, symptomatic DVT has also been found among
23.47% patients who reported Achilles tendon repair and underwent non-operative and
operative treatment, in another retrospective study (Makhdom et al. 2013). Graduated
compression stockings are typically prescribed in units of millimetres of mercury (mmHg)
and also represent the quantity of pressure that is applied on the legs, by the stockings. The
pressure of gradient is found to be strongest near the ankles and generally decreases as it
moves up the legs. There is lack of collective evidence on the benefits of graduated
compression stockings as an effective treatment method, for DVT. This calls for the need of
conducting a systematic review to determine its impacts in preventing DVT among post-
operative orthopaedic patients.

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Research question
What are the impacts of graduated compression stockings to prevent DVT in post-
operative orthopaedic patients?
Research aim
To determine the effects of GCS to prevent DVT in post-operative patients
Research objectives
 To explore the benefits of GCS on patients
 To explore the negative impacts of GCS on patients
 To identify the mechanism of action of GCS in reducing DVT.
Methodology
Search strategy
The MEDLINE and CINAHL databases were searched for retrieving articles, relating
to the usage of GCS in preventing DVT among patients. The key search terms were namely,
“graduated compression stockings”, “DVT”, “deep venous thrombosis”, “postoperative”,
“patients”, “impact”, and “effect” (McGowan et al. 2016). The search terms were combined
with boolean operators AND, NOT and OR that helped in either broadening or narrowing
down the hits obtained from the databases.
Selection criteria
The inclusion and exclusion criteria followed for extracting relevant articles are cited
below:
Inclusion criteria Exclusion criteria
Peer reviewed articles Manuscripts
Published on or after 2012 Published before 2012
Published in English Foreign language

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Focus on impact of GCS in DVT
management and prevention
Abstracts
Table 1- Criteria for article selection
Data collection and extraction
Following use of the Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA), data extraction forms were used for determining relevance of the
information present in the collected literature sources, obtained from the databases (refer to
appendix). A narrative analysis approach was adopted for the particular study where the
research phenomenon was discussed by retrieving concepts and point of views from the
extracted articles.
Critical appraisal
The EBL checklist was used for critically evaluating the relevance of the articles and
determining the reliability, validity and trustworthiness of the findings presented in those
scholarly pieces of evidences (refer to appendix). The table given below discusses the state
of the science related to use of GCS from a theoretical and circumstantial point of view of the
researchers, who have conducted investigations on the topic earlier.
Results
Description of included studies
Authors Geographical
location
Participants
and sample
size
Study design Intervention
Ayhan et al.
(2015)
Ankara, Turkey 219 patients RCT Group I: low-
pressure, knee-

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length GCS;
Group II: low-
pressure, thigh-
length GCS;
Group III:
moderate-
pressure, knee-
length GCS
(anticoagulant
administered to
both groups)
Kahn et al.
(2014)
Canada 806 patients RCT Case: active
GCS(30–40 mm
Hg at ankles)
Control: equal
appearing
placebo GCS
(less than 5 mm
Hg at ankles)
Loomba et al.
(2012)
USA 6 trials Meta-analysis Application of
thigh-length
GCS and knee-
length GCS
amid inpatients,
for DVT

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prophylaxis
Jayaraj and
Meissner (2015)
USA 69 consecutive
patients having
acute DVT
RCT Case: GCS
compression
Control: No
GCS
compression
(anticoagulant
administered to
both groups)
Table 2- Narrative overview of included studies
Outcomes of the included studies
Authors Outcomes
Ayhan et al. (2015) 79·5% patients in group III and 52·1%
patients remaining in in group II reported
problems like tightness, itching, heat, skin
redness, oedema, and pain on toe edges,
during usage of GCS (p < 0·001). The GCS
were described by patients as extremely
comfortable in group I (p < 0·001).
Significant DVT was not observed in the
groups.
Kahn et al. (2014) Mean age of the patients was 55 years and
60% of them were male. In active GCS
group, mean (SD) pain severity at baseline
and 60 days were 5.18 (3.29), and 1.39

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(2.19), respectively. On the other hand, in
the placebo GCS group, mean (SD) pain
severity at baseline and 60 days were 5.38
(3.29) and 1.13 (1.86), respectively. No
important differences were observed in the
pain scores between the two groups at any
point.
Jayaraj and Meissner (2015) An analysis of both Villalta-Prandoni Score
and Venous Clinical Severity scores
suggested lack of differences between post-
thrombotic DVT between groups. Burden of
post-thrombotic syndrome was
meaningfully higher for Villalta-Prandoni
Score instrument (∼75%) in comparison to
Venous Clinical Severity Score instrument
(∼30%) during follow-up.
Loomba et al. (2012) Usage of a fixed-effects model suggested
that upon comparing both knee-length and
thigh-length GCS, thigh-length GCS were
found to offer a reduction in risk of
developing DVT, in contrast to the former
GCS (odds ratio 1.197, confidence interval
0.983–1.458). Nonetheless, the finding was
insignificant.
Table 2- Overview of outcomes

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Discussion
The findings presented above in the narrative overview are not in accordance with
those stated by Subbiah et al. (2016) who conducted a systematic review and meta-analysis
and elaborated that amid patients suffering from DVT, usage of elastic GCS fails in
significantly reducing the onset and development of post thrombotic syndrome. The same had
been mentioned in another systematic review that use of elastic GCS did not create any
positive impact in the onset and progress of post-thrombotic syndrome, nor did it provide
relief from pain to the patients who had been selected for the trial (Berntsen et al. 2016).
Nonetheless, the benefits of GCS in preventing and reducing risks of DVT among patients
who had been recently operated was clearly congruent to the results reported by Sachdeva et
al. (2014). Owing to 1% incidence of DVT in the treatment group, as reported by the
literature that had been included in the systematic review, the researchers stated that GCS are
highly effective in reducing the risks of DVT development amid hospitalised patients, with
presence of adequate evidences that favoured usage of GCS in orthopaedic and general
surgery.
The benefits of GCS, as evidenced from the 4 articles that have been appraised for the
study can also be supported by the fact that these GCS exert utmost degree of firmness at the
ankles, and stage or severity of compression exerted, progressively drops up the garment,
thus lowering the chances of DVT development. Furthermore, owing to the fact that GCS are
particularly designed for ambulatory patients and those who have been recently operated, the
technical and medical specifications that encompass durability and consistency helps in
providing precise amount of pressure at the ankles and related graduation of compression
(Lim and Davies 2014). According to Hague, Pherwani and Rajagopalan (2017) the basic
principle of treatment therapies that focus on implementation of GCS focuses on exertion of a
measured pressure on the affected limbs. The unit of pressure is commonly denoted in

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millimetres of mercury (mmHg), whereby the external pressure applied prevents DVT
development in the symptomatic/affected limb. Additionally, the mechanism of GCS by
which DVT is eliminated or reduced encompasses augmentation of venous blood flow, which
in turn brings about a decrease in the stasis of venous blood. Subsequently, blood volume
reduces that lowers the reflux in the affected superficial or deep veins. The findings presented
above are also in accordance with the fact that GCS lower the pathologically raised venous
pressure, thus accelerating blood flow in microcirculation.
The impacts of GCS as identified from the narrative analysis were also in accordance
with the results published in another article where GCS failed to reduce walking performance
of patients with intermittent claudication. Additionally, calf muscle oxygenation was also
found to increase amid the patients, following administration of GCS, thereby providing
support to the fact that GCS are beneficial for preventing and/or delaying DVT (Cavalcante
et al. 2017). Quesada et al. (2015) also confirmed the effects of GCS by stating that GCS
bring about an increase in the temperature of the skin, at locations that are in contact with the
compression garment, and does not create any impact on the heart rate or fatigue, as
perceived by the patients, while running.
Furthermore, it was also found that regions of the body such as, abductor, vastus
lateralis, and semitendinosus that are not in contact with GCS also report an increase in the
skin temperature, hence supporting the statement that this compression therapy increases
blood circulation in the limbs. Book et al. (2016) opined that use of GCS among healthy
volunteers was associated with a significant reduction in the amount of deoxyhaemoglobin
(HHb) in legs during baseline (HHb, p = 0.001), HHb and whole blood volume during
exercise (total hemoglobin, p = 0.01; HHb, p = 0.02). This further elaborated the fact that
GCS prevents formation of tenderness, swelling, or pain in the affected legs, thereby

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lowering the risks of patients from being affected by DVT. Hence, it can be stated that
application of GCS helps in lowering risks of DVT among hospitalised patients.
Büyükyılmaz et al. (2015) also conducted a risk level analysis for deep vein
thrombosis among Turkish patients who had undergone orthopaedic surgery. While 67.6% of
the patients were made to wear GCS, 62.7% of them had been administered liquid infusion.
Upon performing a binary logistic regression, it was found that patients wearing GCS
demonstrated a moderate risk score, in comparison to their counterparts (12.77 ± 5.66). Some
of the major risk factors associated with DVT were obesity, aging, acute disease, chronic
disease, and immobility, which in turn reduced the likelihood of patients from developing
DVT, upon subjecting them to GCS.
Rastel and Lun (2018) elaborated on the impacts of open toe GCS by stating that
these assist nursing professionals in checking the toes of patients, and also create the
provision for anticipation of side effects, due to the pressure exerted by the stockings. They
further illustrated that inadequate wearing of GCS or insufficient GCS made patients manifest
presence of lesions after having undergone a surgery. In addition, they also stated that at
times the huge pressure exerted by GCS result in the onset of pain, discomfort and skin
injuries. The findings presented in the narrative analysis can also be supported by the fact that
researchers have recognised the increased likelihood of onset of DVT amid patients
undergoing surgeries, specifically among those who are not able to mobilise immediately
after the surgical procedures, such as, neurosurgical and orthopaedic patients.
On conducting a review of literature from scholarly databases, it was found that
pneumatic compression must be administered in combination with chemoprophylaxis for
lowering the risks of DVT among surgical patients (O’connell et al. 2016). Stein et al. (2014)
also measured the impacts of GCS on venous blood velocity among hospitalised patients and

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found no significant increase in the mean or peak venous velocity in the popliteal and/or
femoral veins, upon administration of GCS. The fact that thigh-length GCS failed to produce
a significant impact on the vein blood velocity while the patients were at a supine position,
thus contradicting the findings of the narrative analysis.
Strength and Limitation
The strength of the study conducted by Ayhan et al. (2015) is its high sample size.
The authors included 219 patients in the randomised control trial and the same were divided
into three different groups (Whitehead, Sully and Campbell 2014). All the participants were
blinded about the study and this can be regarded as other strength of the study conducted by
Ayhan et al. (2015). The main strength of the study conducted by Kahn et al. (2014) is, its
large sample size of 803 patients selected from the hospitals of U.S and Canada. This large
sample size helped to reduce the chances of getting biased results. The limitation of the study
is pain scale was access based on self-reported 100-point numerical pain score and thus can
include personal bias. On the other hand, poor sample size can also be regarded as one of the
limitations of the randomised control trial conducted by Jayaraj and Meissner (2015) as it
included only 69 patients. According to Parahoo (2014) the randomised control trial having
100 or more participants help to reduce the chances of getting biased results. The strength of
the study is however, its process of data collection as it used two different tools for the
analysis of the severity of pain. According to Jones (2013) use of single self-reported pain
assessment tool might lead to the generation of biased results and this can be overcome by the
use of the two different tools. The main strength of the study conducted by Loomba et al.
(2012) is its study design. Loomba et al. (2012) conducted a meta-analysis of the randomised
control trial that falls under the level of evidence one. Moreover, its high level of confidence
interval can also be considered as one of the strengths of the study.

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Clinical implications
The analysis of the study conducted Kahn et al. (2014) highlighted ECS with
graduated compression is in-effective in reducing pain among the patients with acute
proximal DVT. Similarly the RCT study conducted by Jayaraj and Meissner (2015)
highlighted the graduated compression stockings is not effective in decreasing the overall
incidence of post-thrombotic syndrome. The co-factor which was aligned with the
development of DVT is obesity. Thus the nursing professionals must concentrate in
maintaining a normal body mass of the patients who are vulnerable in developing DVT. The
meta-analysis of the randomised control trial conducted by Loomba et al. (2012) showed that
irrespective of the length of the stockings, be it thigh length and or knee-length stocking, the
pressure compressor is not effective in preventing prophylaxis of the deep vein thrombosis.
The study conducted by Ayhan et al. (2015) showed that use of low-pressure knee-length
graduated compression stockings is more comfortable in comparison to the low-pressure
thigh-length graduated compression stockings and moderate pressure knee-length graduated
compression stockings. The main nursing implications will thus be directed towards the use
of the knee-length graduated compression stockings however, the RCT study conducted by
Ayhan et al. (2015) failed to show the effectiveness of graduated stockings in reducing the
severity of DVT. Moreover, it also considered the level of comfort of the patients and not the
effectiveness of the graduated compression stockings in curing DVT.
Development of clot in the legs of patients, having undergone orthopaedic surgery, is
a matter of major concern for healthcare providers, owing to the fact that clots can develop
and break free, thus travelling through the bloodstream. On reaching the lungs they can also
lead to pulmonary embolism. Therefore, the primary aim of healthcare professionals would
focus on reducing the risks of DVT, by administering extreme pressure on the lower portions
of their feet and leg, with compression at the calf muscles. After the patients lie in bed, blood

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will have a tendency of pooling in at their calf, thus creating a favourable environment for
clot formation. Thereby, application of the GCS will allow the patients to gain mobility,
while lowering their risks of suffering from DVT. In addition, the GCS will prevent the
excess accumulation of fluid in the legs, thus maximising health of the patients.
Conclusion
Thus, it can be concluded that GCS are administered to patients undergoing
orthopaedic surgery, with the aim of improving blood circulation and lowering the risk of
formation of subsequent blood clots. These stockings are primarily manufactured from
stretchy stockings that have the property of gently squeezing the legs. These stockings sit
tight around the ankles of the patients and are found to exert lesser compression, while the leg
is moved upwards. Under circumstances that are marked by a noticeable constriction in blood
circulation, there lies the possibility of the incidence of venous disorders such as, oedema,
skin alterations, like hyperpigmentation, venous stasis ulcers, lipodermatosclerosis, and
circulatory disorders. An analysis of the articles included in the review also suggested that the
GCS have the unique property of providing tight compression, which in turn promotes
circulation, by energising the fatigued and tired legs, thus preventing and/or reducing
swelling. It is a well-known phenomenon that under circumstances marked by an impairment
in bloodstream circulation, there is a tendency of blood to flow to the lower extremities that
leads to the onset of a range of circulatory problems. Application of the GCS allows
movement of the blood towards the heart, through the veins. In addition, unlike athletic
stockings, traditional dress, and socks, the GCS utilise a sturdier elastic, with the aim of
exerting a momentous pressure on the legs, ankles and feet.
Thus, from the review of the articles it can be stated that there are no significant
scientific basis behind the use of the graduated compression stockings towards reducing the
severity of the deep vein thrombosis. The review of the articles also highlighted that

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irrespective of the length of the stockings like knee length or thigh length stockings, the
application of the graduated compression stockings is ineffective in making significant
difference in the pain recovery arising out of DVT reducing in the prophylaxis of DVT.
Pressure of the graduated compression stockings (low, moderate or high) was found to have
any significant impact in reducing the severity of DVT or the process of development of
DVT among the vulnerable population. The review of the paper on the other hand sated that
obesity is an important determining factor behind the development of the DVT and thus the
nursing implications must be directed towards proper management of the weight of the
vulnerable population.

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a difference from each other and from a randomised controlled trial?. Contemporary clinical
trials, 38(1), pp.130-133.
Zarchi, K. and Jemec, G.B., 2014. Delivery of compression therapy for venous leg
ulcers. JAMA dermatology, 150(7), pp.730-736.

22SYSTEMATIC REVIEW
Appendix
PRISMA chart
Figure 1- PRISMA flowchart

23SYSTEMATIC REVIEW
Critical review of included articles
EBL Critical Appraisal Checklist-
Ayhan, H., Iyigun, E., Ince, S., Can, M.F., Hatipoglu, S. and
Saglam, M., 2015. A randomised clinical trial comparing the
patient comfort and efficacy of three different graduated
compression stockings in the prevention of postoperative deep
vein thrombosis. Journal of clinical nursing, 24(15-16),
pp.2247-2257.
Yes
(Y)
No
(N)
Unclear
(U)
N/A
Section A:
Population
Is the study population representative of all
users, actual and eligible, who might be
included in the study?
It was conducted at the gynecology, general
surgery, urology, and obstetrics departments.
The researchers conducted the trial with the
help of purposive Sampling where the
sample was selected based on the population
characteristics and principal objectives of the
study. Hence, the sampling can be stated as
selective, subjective, and judgmental.
√

24SYSTEMATIC REVIEW
Are inclusion and exclusion criteria
definitively outlined?
The researchers clearly defined the inclusion
criteria with patients who are at least 18
years of age, having undergone pelvic and
abdominal surgery, and been categorised as
high risk for postoperative development of
DVT were included in the trial. Those
patients who did not have any previous
history of postoperative anticoagulation were
also included. Clearly defined exclusion
criteria encompassed presence of
contraindication for wearing GCS, and
patients with DVT near lower extremity.
√
Is the sample size large enough for
sufficiently precise estimates?
Though sample size was calculated by using
power and a particular package program, it
was limited and required larger sample size
for determining the efficacy of graduated
compression stockings.
√
Is the response rate large enough for √

25SYSTEMATIC REVIEW
sufficiently precise estimates?
79.5% response rate in group III (moderate-
pressure, knee-length GCS) can be indicated
as a good completion or return rate by the
patients were included in the trial. 52.1%
response rate by patients who are included in
group II (low-pressure, thigh-length GCS)
suggested that a moderate proportion of
them would accurately respond to the
intervention that had been applied.
Is the choice of population bias-free?
The presence of population bias can be
clearly eliminated, since the patients who
had been selected for the trial were
completely representative of the entire
population that was intended to be analysed (
abdominal and pelvic surgery patients). The
researcher has clearly stated the reason for
conducting the trial in the aforementioned
units in order to obtain large number of
abdominal pelvic surgery clients.
√
If a comparative study:
Were participants randomized into groups?
√ √
√

26SYSTEMATIC REVIEW
All the patients were randomised into three
groups, according to the types of GCS that
was administered to them, in relation to their
compliance and comfort. All the three
groups at 73 patients each, hence proving
proper randomisation.
Were the groups comparable at baseline?
The clinical and socio-demographic
characteristics of all patients in the three
groups were compared at baseline, with
some of the major characters being gender,
educational status, and surgery types.
Comparing the data collected at the
beginning of the trial helped in better
determination of the effects of the three
types of GCS, which were administered to
the patients.
If groups were not comparable at baseline,
was incomparability addressed by the
authors in the analysis?
Was informed consent obtained? √

27SYSTEMATIC REVIEW
Written and informed consent was obtained
from all the patients in the study.
Nonetheless, specific information about the
mechanism of informed consent was not
provided by the researchers in the form of
any supplementary file at the end of the
literature.
Section B:
Data Collection
Are data collection methods clearly
described?
The researchers clearly stated that following
randomisation of the patients to the three
groups, an anticoagulant drug was
administered regularly in subcutaneous
manner. After encouraging the patients to
perform ankle exercises, and remain
mobilized all day, while putting on the GCS,
data collection comprised of conduction of a
neurovascular examination for the lower
extremities. The patients were also evaluated
for the immobilization status, with the use of
a four-point Mobilization Assessment Scale.
√
If a face-to-face survey, were inter-observer
and intra-observer bias reduced?
√

28SYSTEMATIC REVIEW
Is the data collection instrument validated?
The concept of data collection validity is not
clearly stated; however, the mobilization
assessment scale has been developed
previously by another scientist Brodner and
his colleagues in 1999. In addition,
neurovascular assessment of lower
extremities is typically performed for
detecting or indications of compartment
syndrome or acute ischemia, following
surgical procedures in patients.
√
If based on regularly collected statistics, are
the statistics free from subjectivity?
Descriptive statistical analysis was
conducted with the help of SPSS software,
thus making it free from any kind of
subjectivity. Conduction of a chi-square test
also facilitated determination of correlation
between the obtained numerical variables.
√
Does the study measure the outcome at a
time appropriate for capturing the
intervention’s effect?
√

29SYSTEMATIC REVIEW
Is the instrument included in the publication?
The data collection tool is not included in the
form of a supplementary file.
√
Are questions posed clearly enough to be
able to elicit precise answers?
√
Were those involved in data collection not
involved in delivering a service to the target
population?
Radiologists evaluated the patient and were
unaware of the groups in which they were
randomised.
√
Section C:
Study Design
Is the study type / methodology utilized
appropriate?
However, conducting a multicenter RCT
would have produced better results.
√
Is there face validity?
The mobilization scale had been previously
tested.
√
Is the research methodology clearly stated at
a level of detail that would allow its
replication?
Although clear explanations are provided,
adding the data collection tools would have
√

30SYSTEMATIC REVIEW
been beneficial.
Was ethics approval obtained?
Approval was obtained from the Research
Ethics Board of the hospital.
√
Are the outcomes clearly stated and
discussed in relation to the data collection?
Conduction of descriptive statistical analysis
helped in expressing numerical variables and
quantitative variables in the form of
percentage numbers mean median and min-
max values.
√
Section D:
Results
Are all the results clearly outlined?
Patients with GCS were reported to be
extremely comfortable in group I, compared
to those in group II and III who faced
problems with its use. DVT were not found
in any of the groups.
√
Are confounding variables accounted for? √
Do the conclusions accurately reflect the
analysis?
It suggests that use of low-pressure, knee-
length GCS Is an effective strategy for
√

31SYSTEMATIC REVIEW
preventing postoperative DVT among
surgical patients.
Is subset analysis a minor, rather than a
major, focus of the article?
√
Are suggestions provided for further areas to
research?
The researchers highlight the need to
conduct further studies with large sample
sizes that include other types of surgical
patient such as, orthopedic, cardiovascular,
and cranial.
√
Is there external validity? √
Calculation for section validity: (Y+N+U=T)
If Y/T <75% or if N+U/T > 25% then you can
safely conclude that the section identifies
significant omissions and that the study’s validity
is questionable. It is important to look at the
overall validity as well as section validity.
Calculation for overall validity:
(Y+N+U=T)
If Y/T ≥75% or if N+U/T ≤ 25% then
you can safely conclude that the
study is valid.
Section A validity calculation: 1/ 4= 25% not
valid
Section B validity calculation: 5/ 7= 71% not
Overall validity calculation:
11/ 22 = 50% not valid

32SYSTEMATIC REVIEW
valid
Section C validity calculation: 1/ 5= 20% not
valid
Section D validity calculation: 4/ 6= 67% not
valid

33SYSTEMATIC REVIEW
EBL Critical Appraisal Checklist-
Kahn, S.R., Shapiro, S., Ducruet, T., Wells, P.S., Rodger,
M.A., Kovacs, M.J., Anderson, D., Tagalakis, V., Morrison,
D.R., Solymoss, S. and Miron, M.J., 2014. Graduated
compression stockings to treat acute leg pain associated with
proximal DVT. Thrombosis and haemostasis, 112(12),
pp.1137-1141.
Yes
(Y)
No
(N)
Unclear
(U)
N/A
Section A:
Population
Is the study population representative of all
users, actual and eligible, who might be
included in the study?
The study included all patients from 24
Canadian and United States centres, who
reported the presence of initial episodes of
symptomatic, proximal DVT, thus being
representative of the entire population.
√
Are inclusion and exclusion criteria
definitively outlined?
The researchers clearly stated that all
patients recruited from 2004-2010, who
manifested first episodes of proximal,
symptomatic DVT were included in the trial.
Exclusion criteria comprised of those
√

34SYSTEMATIC REVIEW
patients who reported contraindications to
usage of GCS, had geographic
inaccessibility, were administered
thrombolytic therapy for acute DVT
treatment, or had lifespan less than six
months.
Is the sample size large enough for
sufficiently precise estimates?
Total sample size of 800 for SOX Trial was
large to precise the outcome estimates.
√
Is the response rate large enough for
sufficiently precise estimates?
Of the 803 patients, 409 reported active ECS
with a moderate response rate of 50.93%.
Thus, the response rates were not adequate
for precise estimates.
√
Is the choice of population bias-free?
There is no population bias in the research,
since all patients were enrolled between a
long period of time starting from 2004 till
2010, across the United States and Canada,
which prevented the researchers from
creating any selection effect. Hence, it can
√

35SYSTEMATIC REVIEW
be stated that the sample recruited was
completely representative of the population
that was intended to be analysed.
If a comparative study:
Were participants randomized into groups?
The participants were randomised into
groups namely, the intervention group (409
patients) where they received active
graduated knee-high ECS, and the control
group (394 patients) where placebos
stockings that were identical in appearance
were administered. While those GCS in the
intervention group applied 30–40 mm Hg
pressure at the ankles, those in the placebo
group applied >5 mm Hg compression.
Were the groups comparable at baseline?
Baseline characteristics were compared for
both the active stockings and placebo
groups. Baseline characters were measured
for age, gender, body mass index, ethnicity,
risk factors for venous thrombosis, proximal
extent of DVT, and treatment for DVT.
√
√
√

36SYSTEMATIC REVIEW
Measuring the outcomes at baseline helped
in better assessment of the contrasting
effects exerted by the intervention and
Placebo GCS.
If groups were not comparable at baseline,
was incomparability addressed by the
authors in the analysis?
Was informed consent obtained?
All patients were asked to provide their
written informed consent, prior to
participation in the study. However,
informed consent letter was not provided by
the researcher has a supplementary material.
√

37SYSTEMATIC REVIEW
Section B:
Data Collection
Are data collection methods clearly
described?
The researchers accurately described the
data collection procedure that involved
assessment of leg pain severity, based on 11-
point numerical pain rating scale.
Cumulative incidence of PTS was the
primary outcome of the trial which was
diagnosed at 6 months, or after by using a
criteria which had originally been described
by another researcher Ginsberg.
√
If a face-to-face survey, were inter-observer
and intra-observer bias reduced?
√
Is the data collection instrument validated?
Validity of the data collection tool can be
established by the fact that it had been used
by Ginsberg and colleagues for preventing
and treating postphlebitic syndrome.
√
If based on regularly collected statistics, are
the statistics free from subjectivity?
The researchers did not provide adequate
details for the statistical measurement that
√

38SYSTEMATIC REVIEW
had been employed for analysing the
primary and secondary outcomes, in relation
to leg pain severity in DVT-affected legs.
Taking into consideration the fact that
reports from patients were used for analysing
the severity of pain, in relation to the
continued usage of GCS, there are chances
of subjectivity in the statistics. The results
were derived from the personal judgment of
the patients about weather paint severity
likely occurred.
Does the study measure the outcome at a
time appropriate for capturing the
intervention’s effect?
√
Is the instrument included in the publication?
The instrument used for data collection is
not included in the publication in form of
any supplementary material.
√
Are questions posed clearly enough to be
able to elicit precise answers?
The questions that were post were not
elicited by the researchers. Hence, precision
√

39SYSTEMATIC REVIEW
of answers cannot be estimated
Were those involved in data collection not
involved in delivering a service to the target
population?
All the patients, study personnel, and
physicians were blinded to allocation and
treatment.
√
Section C:
Study Design
Is the study type / methodology utilized
appropriate?
Conduction of an RCT was appropriate for
this particular research since in only one
previously conducted study had examined
the impacts of GCS compression on DVT
associated leg pain. Nonetheless, a before
and after study would have helped the
researchers in better determining the impacts
of GCS in reducing DVT and pain severity,
amid the cohort, when it was followed for a
specific period of time.
√
Is there face validity?
The tool used for assessment helped in
covering the concept of GCS and pain
severity in the legs of patients, as it
√

40SYSTEMATIC REVIEW
purported to measure.
Is the research methodology clearly stated at
a level of detail that would allow its
replication?
Additional details on methodology are
required.
√
Was ethics approval obtained?
The research ethics boards had given an
approval.
√
Are the outcomes clearly stated and
discussed in relation to the data collection?
The primary and secondary outcomes were
clearly stated.
√
Section D:
Results
Are all the results clearly outlined?
Mean (SD) pain severity at baseline and at
60 days were 5.18 (3.29) and 1.39 (2.19) in
active ECS (case). It was 5.38 (3.29) and
1.13 (1.86) in the placebo ECS group, thus
showing no noteworthy differences between
the two groups.
√
Are confounding variables accounted for? √

41SYSTEMATIC REVIEW
Researchers did not provide adequate
information on the same.
Do the conclusions accurately reflect the
analysis?
It stated that ECS did not decrease pain amid
patients having acute proximal DVT.
√
Is subset analysis a minor, rather than a
major, focus of the article?
√
Are suggestions provided for further areas to
research?
√
Is there external validity? √
Calculation for section validity: (Y+N+U=T)
If Y/T <75% or if N+U/T > 25% then you can
safely conclude that the section identifies
significant omissions and that the study’s validity
is questionable. It is important to look at the
overall validity as well as section validity.
Calculation for overall validity:
(Y+N+U=T)
If Y/T ≥75% or if N+U/T ≤ 25% then
you can safely conclude that the
study is valid.
Section A validity calculation: 1/ 4= 25% not
valid
Section B validity calculation: 5/ 7= 71% not
Overall validity calculation:
11/ 22 = 50% not valid

42SYSTEMATIC REVIEW
valid
Section C validity calculation: 1/ 5= 20% not
valid
Section D validity calculation: 4/ 6= 67% not
valid

43SYSTEMATIC REVIEW
EBL Critical Appraisal Checklist
Loomba, R.S., Arora, R.R., Chandrasekar, S. and Shah, P.H.,
2012. Thigh-length versus knee-length compression stockings
for deep vein thrombosis prophylaxis in the inpatient
setting. Blood Coagulation & Fibrinolysis, 23(2), pp.168-171.
Yes
(Y)
No
(N)
Unclear
(U)
N/A
Section A:
Population
Is the study population representative of all
users, actual and eligible, who might be
included in the study?
√
The review focused on determining the impacts
of thigh-length versus knee-length GCS among
inpatients, thus being representative of the
entire population.
Are inclusion and exclusion criteria definitively
outlined?
√
The reviewers used explicit exclusion and
inclusion criteria for selecting the articles that
were best fit for the phenomenon being
investigated. However, detailed criteria was not
stated.
Is the sample size large enough for sufficiently
precise estimates?
√
Only 6 articles were included in the meta-
analysis that resulted in bias in the results.
Is the response rate large enough for
sufficiently precise estimates?
√
Is the choice of population bias-free? √
The articles were thoroughly extracted by a
well-formulated research strategy that reduced

44SYSTEMATIC REVIEW
bias.
If a comparative study:
Were participants randomized into groups?
Were the groups comparable at baseline?
All studies evaluated the baseline characters of
the patients.
If groups were not comparable at baseline, was
incomparability addressed by the authors in the
analysis?
√
√
Was informed consent obtained? √
Section B:
Data Collection
Are data collection methods clearly described? √
MEDLINE, Cochrane Library, OVID and
PubMed were thoroughly searched with the use
of key terms like knee-length compression
stockings, thigh-length compression stockings,
DVT, and compression stockings.
If a face-to-face survey, were inter-observer
and intra-observer bias reduced?
√
Is the data collection instrument validated? √
fixed effects model was utilized for analysis
If based on regularly collected statistics, are the
statistics free from subjectivity?
Conducting of a meta-analysis with the use of
statistical software MedCalc software package
prevented subjectivity of data since results from
other studies were summarized in numerical
forms. Odds ratio calculation also prevented
√

45SYSTEMATIC REVIEW
statistical subjectivity.
Does the study measure the outcome at a time
appropriate for capturing the intervention’s
effect?
√
Is the instrument included in the publication? √
The researchers provided a detailed
representation of the results that were obtained
after conducting a meta-analysis, in terms of
odds ratio for all the studies that were included
in the review.
Are questions posed clearly enough to be able
to elicit precise answers?
√
Were those involved in data collection not
involved in delivering a service to the target
population?
√
Section C:
Study Design
Is the study type / methodology utilized
appropriate?
√
Collection of information from several articles
helped in providing a detailed insight into the
effectiveness of GCS, in relation to providing
protection against DVT, and also helped in
generalizing the findings to a wider perspective.
Is there face validity? √
The results were viewed accurately, with
respect to the concept of GCS and its efficacy

46SYSTEMATIC REVIEW
that was purported to be measured.
Is the research methodology clearly stated at a
level of detail that would allow its replication?
√
Similar meta-analysis can be conducted with
recent evidences for obtaining valid results
Was ethics approval obtained? √
Are the outcomes clearly stated and discussed
in relation to the data collection?
√
DVT development among inpatients was
correctly determined with the help of odds ratio
and confidence intervals
Section D:
Results
Are all the results clearly outlined? √
Thigh-length stockings helped in better risk
reduction of DVT development, in comparison
to knee-length (odds ratio 1.197, confidence
interval 0.983–1.458).
Are confounding variables accounted for? √
Do the conclusions accurately reflect the
analysis?
√
No significant findings were concluded from
the review
Is subset analysis a minor, rather than a major,
focus of the article?
√
Are suggestions provided for further areas to
research?
√
The researchers elaborated on conducting
future RCTs for determining the actual

47SYSTEMATIC REVIEW
efficiacy of GCS.
Is there external validity? √
Calculation for section validity:
(Y+N+U=T)
If Y/T <75% or if N+U/T > 25%
then you can safely conclude that
the section identifies significant
omissions and that the study’s
validity is questionable. It is
important to look at the overall
validity as well as section validity.
Calculation for overall validity: (Y+N+U=T)
If Y/T ≥75% or if N+U/T ≤ 25% then you can
safely conclude that the study is valid.
Section A validity calculation:
Y/T = 3/6 = 50%
Section B validity calculation:
Y/T = 1/4 = 25%
Section C validity calculation:
Y/T = 2/5 = 40%
Section D validity calculation:
Y/T = 1/4 = 25%
Overall validity calculation: 7/19 = 37%

48SYSTEMATIC REVIEW
EBL Critical Appraisal Checklist
Jayaraj, A. and Meissner, M., 2015. Impact of graduated
compression stockings on the prevention of post-thrombotic
syndrome-results of a randomized controlled
trial. Phlebology, 30(8), pp.541-548.
Yes
(Y)
No
(N)
Unclear
(U)
N/A
Section A:
Population
Is the study population representative of all
users, actual and eligible, who might be
included in the study?
√
The researchers conducted the study among
patients who had ben diagnosed with acute
DVT, thereby increasing representativeness of
the study population.
Are inclusion and exclusion criteria definitively
outlined?
√
The researchers clearly defined the exclusion
criteria that included exclusion criteria included
incapability to give consent, contraindications
to anticoagulation; previous DVT: DVT in the
calf veins; chronic venous insufficiency
(CEAP class C4–C6); arterial insufficiency
(ABI <0.6); and usage of compression
stockings
Is the sample size large enough for sufficiently
precise estimates?
√
69 patients were selected for the research.
Is the response rate large enough for
sufficiently precise estimates?
√
Is the choice of population bias-free? √

49SYSTEMATIC REVIEW
There was no selection bias because
participants had been recruited across multiple
health specialties, thus increasing their
representativeness.
If a comparative study:
Were participants randomized into groups?
Were the groups comparable at baseline?
Baseline characteristics of both intervention
and control participants were measured during
the research.
If groups were not comparable at baseline, was
incomparability addressed by the authors in the
analysis?
√
√
Was informed consent obtained? √
Patients were provided sealed envelope
containing information sheet, following which
they were recruited only if they provided
voluntary agreement for participation in the
research.
Section B:
Data Collection
Are data collection methods clearly described? √
The researchers used two different scoring
systems namely, Venous Clinical Severity
Score and Villalta-Prandoni Score for
determining the onset of post-thrombotic
syndrome in the patients.
If a face-to-face survey, were inter-observer
and intra-observer bias reduced?
√
Is the data collection instrument validated? √

50SYSTEMATIC REVIEW
Grading of the data collection tools was
validated by previous researchers who had
utilized them for investigation purpose.
If based on regularly collected statistics, are the
statistics free from subjectivity?
The researchers calculated cumulative
incidences based on Kaplan–Meier life tables.
This prevented data subjectivity since the
scores were numerically analysed to explore the
impacts of GCS.
√
Does the study measure the outcome at a time
appropriate for capturing the intervention’s
effect?
√
Is the instrument included in the publication? √
The researchers provided accurate details of
their research findings in terms of cumulative
incidence and relative risks of DVT amid the
patients.
Are questions posed clearly enough to be able
to elicit precise answers?
√
Were those involved in data collection not
involved in delivering a service to the target
population?
√
Treatment allocation was not revealed by the
patients at the time of visit to the clinics.
√
Section
C: Is the study type / methodology utilized
appropriate?
√

51SYSTEMATIC REVIEW
Study Design
Randomizing the patients provided the target
population an equal chance of being subjected
to either the intervention or the control group.
This reduced bias in the results and also helped
in determining the impacts of GCS, in
comparison to standard treatment.
Is there face validity? √
The results were accurately interpreted, in
relation to GCS.
Is the research methodology clearly stated at a
level of detail that would allow its replication?
√
Similar RCTs can be conducted by following
the comprehensive research methodology.
Was ethics approval obtained?
No information had been provided by the
researchers.
√
Are the outcomes clearly stated and discussed
in relation to the data collection?
√
The GCS group was demonstrated to have
reduced incidence of DVT, in comparison to
the control group, only during the first month.
Section D:
Results
Are all the results clearly outlined? √
No significant differences were found between
GCS and standard treatment, in relation to the
onset of post-thrombotic syndrome.
Are confounding variables accounted for? √

52SYSTEMATIC REVIEW
Do the conclusions accurately reflect the
analysis?
√
No significant findings were concluded by the
researchers.
Is subset analysis a minor, rather than a major,
focus of the article?
√
Are suggestions provided for further areas to
research?
√
Researchers recommended conduction of a
larger RCT using multiple scoring system.
Is there external validity? √
Calculation for section validity:
(Y+N+U=T)
If Y/T <75% or if N+U/T > 25%
then you can safely conclude that
the section identifies significant
omissions and that the study’s
validity is questionable. It is
important to look at the overall
validity as well as section validity.
Calculation for overall validity: (Y+N+U=T)
If Y/T ≥75% or if N+U/T ≤ 25% then you can
safely conclude that the study is valid.
Section A validity calculation:
Y/T = 3/6 = 50%
Section B validity calculation:
Y/T = 1/4 = 25%
Section C validity calculation:
Overall validity calculation: 7/19 = 37%

53SYSTEMATIC REVIEW
Y/T = 2/5 = 40%
Section D validity calculation:
Y/T = 1/4 = 25%

54SYSTEMATIC REVIEW
Data extraction
PAPER: Ayhan, H., Iyigun, E., Ince, S., Can, M.F., Hatipoglu, S. and Saglam, M., 2015. A
randomised clinical trial comparing the patient comfort and efficacy of three different
graduated compression stockings in the prevention of postoperative deep vein
thrombosis. Journal of clinical nursing, 24(15-16), pp.2247-2257.
Level of Evidence
Country where Data was
collected
Turkey
Introduction-Background Graduated compression stockings along with other
prophylaxis methods are very important in postoperative deep
vein thrombosis prophylaxis management
Research question What is the comfort level of patients in using three different
graduated compression stockings?
What are the efficacies of the graduated compression
stockings in providing the patients comfort and proper
compliance in prevention of postoperative deep vein
thrombosis?
Methods: Research
approach, Research design,
Paradigm, population,
sample Size, Sampling
technique, Data collection,
Data analysis method.
Research approach: Quantitative study
Research design: Randomized control trial
Paradigm: Graduated compression stockings in treating post-
operative deep vein thrombosis
Population: Post-operative patients
Sample Size: 219
Sampling technique: Random sampling

55SYSTEMATIC REVIEW
Data collection: Patient survey in detection of comfort and
nursing observation for the detection of the post-operative
thrombosis
Data analysis method: Quantitative: Statistical
Research Ethics
considerations
Informed consent is taken from the patients who were
recruited in the study and proper permission is taken from the
hospital ethical committee and the hospital administration
committee before the seeking permission from the patients
Results: Main finding The main findings of the results highlighted that knee-length
graduated compression stockings shares similar effectiveness
as other graduated compression stockings with different
pressure frequency and different sizes. The patients
experienced fewer problems while using graduated
compression stockings.

56SYSTEMATIC REVIEW
PAPER: Kahn, S.R., Shapiro, S., Ducruet, T., Wells, P.S., Rodger, M.A., Kovacs, M.J.,
Anderson, D., Tagalakis, V., Morrison, D.R., Solymoss, S. and Miron, M.J., 2014.
Graduated compression stockings to treat acute leg pain associated with proximal
DVT. Thrombosis and haemostasis, 112(12), pp.1137-1141.
Level of Evidence 1
Country where Data was
collected
Canada and U.S
Introduction-Background Acute Deep Venous thrombosis (DVT) leads to pain in leg.
The elastic compression stockings (ECS) help to decrease the
severity of pain by reducing the diameter of distended veins
while increasing the blood flow in the veins.
Research question The main research question was to determine the
effectiveness of ECS in reducing the pain in the leg among
the patients suffering from the acute DVT.
Methods: Research
approach, Research design,
Paradigm, population,
sample Size, Sampling
technique, Data collection,
Data analysis method.
The main research approach was quantitative with research
design include randomized placebo controlled trail. the main
paradigm of the research is comparative study done with
active ECS verses placebo use to prevent DVT. The study
was conducted in 24 different hospitals and included 803
patients. The randomized sampling was done. The data was
collected based on the self-reported 11-point numerical pain
scale and the patient were blinded about the type of ECS. Te
analysis of data was done by statistical analysis of SOX trial.
Research Ethics Informed consent is taken from both the hospital authority

57SYSTEMATIC REVIEW
considerations and from the patients who are included in the trial group.
Results: Main finding The results highlighted that place ECS patients mean pain
score was 3.29 at the based line and 1.86 after 60-day of
follow. In active ECS patient, pain score was 3.29 at baseline
and 2.19 after 60 days follow-up. There were no significant
difference in the pain score based on age, sex and anatomical
extend of DVT.
Discussion The author concluded that ECS do not help to decrease the
level of pain among the patients suffering from acute
proximal DVT.
PAPER: Jayaraj, A. and Meissner, M., 2015. Impact of graduated compression stockings
on the prevention of post-thrombotic syndrome-results of a randomized controlled
trial. Phlebology, 30(8), pp.541-548.
Level of Evidence 1
Country where Data was
collected
Washington USA
Introduction-Background Post-thrombotic syndrome causes chronic complication of
acute deep venous thrombosis lower extremity. The role of
graduated compression stockings for treating post-thrombotic
syndrome and majority of the results highlighted beneficial
effects.
Research question The main research question is to conduct a access the post-
thrombotic syndrome with the help of the multiple scoring

58SYSTEMATIC REVIEW
instruments.
Methods: Research
approach, Research design,
Paradigm, population,
sample Size, Sampling
technique, Data collection,
Data analysis method.
Research approach: Quantitative
Research design: Randomised control trial
Research paradigm: Blinded trials for the development of the
new insights about the role of the graduated compression
stockings.
Sample size: 69 patients suffering from acute deep venous
thrombosis accessed by duplex ultrasonography and treated
with or without graduated compression stockings.
Data collection: Venous Clinical Score and Villalta-Prandoni
score was used to detect pain at an interval of 3, 6, 12, 18 and
24 months.
Data analysis: Comparative numerical analysis of the pains
core
Research Ethics
considerations
Informed consent was taken from the patients who were
recruited in the trial
Results: Main finding There were no significant difference in the pain score during
6 or 12 months of follow-up between both the groups. The
severity of post-thrombotic pain was potentially high in
Villalta-Prandoni Score instrument in comparison to Venous
Clinical Severity Score instrument during 24 months follow-
up. However, obesity factor is found statically significant
indicator for the development of the post-thrombotic

59SYSTEMATIC REVIEW
syndrome
Discussion The authors concluded that the use of the graduated
compression sticking is not significant effective in reducing
the severity of the post-thrombotic syndrome.
PAPER: Loomba, R.S., Arora, R.R., Chandrasekar, S. and Shah, P.H., 2012. Thigh-length
versus knee-length compression stockings for deep vein thrombosis prophylaxis in the
inpatient setting. Blood Coagulation & Fibrinolysis, 23(2), pp.168-171.
Level of Evidence 1
Country where Data was
collected
Wisconsin, USA
Introduction-Background The background of the study mainly focused over how DVT
hampers the quality of the life of the patients in the post-
operative period and increases the length of stay at the
hospital.
Research question The aim of the study to compare the effectiveness of the knee-
length and thigh-length compression stockings for the
effective treatment of the deep vein prophylaxis.
Methods: Research
approach, Research design,
Paradigm, population,
sample Size, Sampling
technique, Data collection,
Data analysis method.
Research approach: Quantitative
Research design: Meta-analysis of the randomised control
trial with fixed effects model
Paradigm: Effective analysis of the graduated-compression
stockings towards reducing the severity of the deep vein
prophylaxis

60SYSTEMATIC REVIEW
Population: meta-analysis of the RCT studies
Statistical analysis of the data was done with the odds ratio of
1.197 and confidence interval of 0.983 to 1.458.
Research Ethics
considerations
Since it was a meta-analysis study, seeking informed consent
from the participants were are applicable however, the authors
cited the works of the other researcher accordingly
Results: Main finding The main findings highlighted that as per the fixed effects
model there was no significant difference in the thigh-length
stockings and compression stockings in reducing the risks of
DVT.
Discussion The meta-analysis thus highlighted that the current data of the
available RCT studies failed to highlight the effectiveness of
both the knee-length compression stockings and thigh-length
stocking in curing prophylaxis of DVT.

61SYSTEMATIC REVIEW
Excluded Articles
Authors Participants and
sample size
Study design Reason for
exclusion
Clarke, M.J.,
Broderick, C.,
Hopewell, S.,
Juszczak, E. and
Eisinga, A., 2016
11 trials with 2906
participants
Systematic review of
the randomised
control trial
The paper is
excluded because it
conducted the
effectiveness of the
compression
stockings in airline
passengers only thus
limiting its
application over the
mass
Rabe, E., Partsch,
H., Hafner, J.,
Lattimer, C., Mosti,
G., Neumann, M.,
Urbanek, T.,
Huebner, M.,
Gaillard, S. and
Carpentier, P., 2018
51 relevant
publications were
chosen for analysis
of the evidence-
based practice
Systematic review of
literature: Secondary
research
This study was
excluded from the
review because the
study detected the
efficacy of the
compression
stockings over the
patients with
lymphatic
complications or
venous disorders and
thus was outside the

62SYSTEMATIC REVIEW
scope of the study
CLOTS Trials
Collaboration,
Dennis, M.,
Sandercock, P.,
Reid, J., Graham, C.,
Murray, G.,
Venables, G., Rudd,
A. and Bowler, G.,
2013
1, 2518 immobile
stroke patients thigh-
length graduated
compression
stockings
And
2, 3014 to thigh-
length or below-knee
graduated
compression
stockings
CLOTS Trials This study was
excluded from the
review because it
was a restricted
population size. The
effectiveness of the
compression
stockings were
studied among the
cardiac patients who
are recovering from
stocks and thus
results obtained
might not be
applicable for older
adults
Lattimer, C.R.,
Kalodiki, E., Kafeza,
M., Azzam, M. and
Geroulakos, G.,
2014
20 healthy subjects
were studied supine
position in their right
leg
A prospective study The study was
excluded because the
main aim of the
study is to quantify
degree graduated
elastic compression
stocking in order to
enhance the process

63SYSTEMATIC REVIEW
of venous emptying.
The quantification of
the venous emptying
is not directly related
to scope of the study
as it failed to
highlight the
effectiveness of
compression
stockings in
reducing the pain of
DVT
Wade, R., Paton, F.
and Woolacott, N.,
2017
11 databases were
accessed for the
selection of the
qualitative paper
published till 2013.
Mainly primary
qualitative study was
selected
Systematic review of
the qualitative study
The main reason
behind the exclusion
of the study is, it
concentrated over
the surgical patients
only. This specified
target group lead to
the exclusion of this
study

64SYSTEMATIC REVIEW