ICC-COMPRESSION QUESTIONNAIRE

FOR HEALTH CARE PROVIDERS (ICC-CQ-H)
Description of the questionnaire

The purpose of the compression questionnaire is to evaluate the effect of different kinds ofcompression materials and systems and its acceptance and experience by the patient.
The compression questionnaire can be used for longitudinal comparative studies (not forcross-sectional studies). It should neither replace a quality of life-instrument nor a study
protocol in which several outcome parameters may be specified, but should help to makepatient orientated feelings with different compression modalities comparable.
The questionnaire consists of two parts. The first part has to be filled out by the health careprovider. The second part has to be filled out by the patient.
The compression questionnaire for the health care provider consists of two subsections.
In the first subsection of the questionnaire, the health care provider describes the patient
and the compression device/ system. In addition, he/ she performs an evaluation of the skinof the limb, which will be treated with the compression device/ system.
In the second subsection, the health care provider performs an evaluation of the limb withcompression immediately after application and at follow up visits as requested in the study
protocol.
In the appendix, an overview of reliable and valid general and disease-specific quality of life
questionnaires is given. It is recommended to use one or more of these questionnaires in
addition to the compression questionnaire.
The compression questionnaire for patients evaluates following aspects:- Wearing time/ dosage of compression- Application and removing of compression- Compression comfort- Complications of compression- Physical functioning in relation to compression- Disease-related symptoms- General experience

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Part 1. Assessment by health care provider – before start of tested
compression
Date: …
ID patient: …

Name health care provider: …
Profession: nurse/ physical therapist/ occupational therapist/ physician/ other: …

General assessment

General information about the patient
1. Date of birth: …
2. Body weight (in kg): …
3. Body height (in m): …

Information about compression to be tested

1. Kind of compression to be tested (intervention or control):Product name:Company:
2. Side of limb with compression: left/ right/ both/ central

3. Compression covers (circle all relevant areas):
Fingers/ hand/ lower arm/ elbow/ upper arm/ breast/ trunkToes/ foot/ ankle/ lower leg/ knee/ thigh/ groin/ hip/ abdomen/ buttock/ genital region

4. Reason of compression:a. Prevention/ treatment/ both (circle)
b. Oedema: yes/ noi. Type of oedema: venous oedema/ lymphoedema/ lipoedema/ other:…….. (circle one or more types)
ii. If venous oedema: cause: …
iii. If lymphoedema: cause: primary (indicate: …
)
secondary: cancer/ infection/ trauma/ obesityc. Venous ulcer: yes/ nod. Deep venous thrombosis: yes/ noe. Post-thrombotic syndrome: yes/ nof. Chronic venous disease: yes/ nog. Other: ….
5. Duration of the disease (with compression): the patient has the disease since (date):
6. Location of the disease to be treated with compression:
Fingers/ hand/ lower arm/ elbow/ upper arm/ breast/ trunkToes/ foot/ ankle/ lower leg/ knee/ thigh/ groin/ hip/ abdomen/ buttock/ genital region
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7. Pressure obtained with the current compression material/ system (measured withPicoPress or Kikuhime; timing is according to the instructions of the study protocol):Rest without gravity

Arm
Measured below the elbow(dorsal part)Arm ishorizontal andhand is
supported

Rest with support

During muscle
contractions (minimaland maximal)Leg
Measured 10-12cm above
medial ankle (at B1)
Leg is horizontal and foot is
supported

PressuremmHg

Standing with support on
Arm is vertical with both feetsupport on the fist
Arm is vertical while
squeezing the hand

Walking on the spot

Patient’s history of compression:

1. Has the patient ever had compression? Yes/ noIf yes, fill the questionnaire further out
If no, go to part 2
2. First compression since: …………….. (date)
3. When was compression applied last time before entering the study: … days ago (ifcompression at this moment = 0 days).

Compression in the past week:

4. In the past week, did the patient wear stockings/ garments: yes/ no
If yes: product namecompany: …
round knitted/ flat knitted
standard/ custom-madesize: toe-cap/ knee –high/ thigh- high/ panty hose
glove/ arm sleeve/ shoulder-cap
other: …
compression pressure range declared by producer: ….. mmHg

5. In the past week, did the patient use intermittent pneumatic compression: yes/ no
If yes pressure: …
mmHg
number of chambers: …
6. In the past week, did the patient wear bandages: yes/ no
If yes: who did apply the bandages: patient/ physical therapist/ nurse/ other: …
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material bandages:
low-elastic or inelastic bandages:
non-cohesive (e.g. Durelast™, Rosidal K™, Comprilan™): yes/nocohesive (e.g. Coban2™, Rosidal CC™): yes/ noelastic bandages:
non-cohesive (e.g. Dauerbine™): yes/ nocohesive (e.g. Coban™): yes/ nosilicone bandages (e.g. Silwrap™): yes/novelcro wraps (e.g. Circaid™): yes/ noother components (e.g. tubular sleeve, padding): …

7. In the past week, how many hours during daytime did the patient wear thecompression device on average (or was compression applied)? … hours a day
8. In the past week, how many hours at night did the patient wear the compression
device on average (or was compression applied)? … hours at night

General history of compression:

9. In the past, has the patient ever worn stockings/ garments? yes/ noIf yes: (indicate all items of stockings/ garments the patient received before entering
the study)
period (from … to …): …
product name: …
company: …
round knitted/ flat knitted
standard/ custom-madesize: toe-cap/ knee –high/ thigh- high/ panty hose
glove/ arm sleeve/ shoulder-cap
other: …
compression pressure range declared by producer: ….. mmHg
10. In the past, has the patient ever had intermittent pneumatic compression? yes/ noIf yes period (from … to …): …
pressure: …
mmHg
number of chambers: …

11. In the past, has the patient ever received bandaging? yes/ noIf yes: (indicate all items of bandaging the patient received before entering the study)
period (from … to …): …
who did apply the bandages? patient/ physical therapist/ nurse/ other: …
material:
low-elastic or inelastic bandages:
non-cohesive (e.g. Durelast™, Rosidal K™, Comprilan™): yes/nocohesive (e.g. Coban2™, Rosidal CC™): yes/ noelastic bandages:
non-cohesive (e.g. Dauerbine™): yes/ nocohesive (e.g. Coban™): yes/ nosilicone bandages (e.g. Silwrap™): yes/novelcro wraps (e.g. Circaid™): yes/ noother components (e.g. tubular sleeve, padding): …
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Skin

1. Make a picture of the skin of the limb that will be covered with the tested
compression in a frontal and lateral view!

2. Make a judgement of the skin that will be covered with the tested compression
material/ system. Indicate whether the skin problem is absent (= circle 0), doubtfully
present (= circle 1) or clearly present (= circle 2). Indicate the region with the skinproblem.
Absent0

Doubtfully
present1

Clearlypresent2

1. Dryness012

2. Local swelling(stagnation of fluid)

0120120120120120

120

120

12012

3. General redness(e.g. evoked bycompression material,infection or sudden
increase of fluid)
4. Local redness(irritation due to highlocal pressure)
5. Strangulation(depression due to unevencompression)
6. Blister or vesicle(local accumulation offluid under the skin)
7. Erosion(loss of epidermis)

8. Ulceration(full thickness skin loss)

9. Papules(solid elevation of skinwith no visible fluid)
10. Other skin problem(please indicate whichproblem):…

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Region with the skinproblem

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Part 2. Assessment of tested compression by health care provider –after application of tested compression (during follow-up)
Date: …

ID patient:

Hour of the day:Name health care provider who assesses the tested compression: …

Compression material

1. Make a picture of the limb with the tested compression in a frontal and lateral view!
2. How well does the compression product/ system cover the whole limb (in relation to thearea which it is intended to cover)? The limb is …
Not covered at all

Completely covered

3. How well does the compression product/ system fit around the covered limb? Thecompression product/ system …
Does not fit at all

Fits completely

4. How do you judge the compression product/ system according to your expectations? Ijudge the compression product/ system as …
Absolutely appropriate

Not appropriate at all

Adherence

5. Make an estimation of the adherence of the patient (by asking for the frequency ofwearing the compression product/ system during the last period or by inspection of skinfor sun tan). The patient is …
Probably completely
adherent

Probably notadherent at all

Adherence= the extent to which the patient’s behaviour matches agreed
recommendations from the prescriber.

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Skin

1. Make a picture of the skin of the limb without tested compression in a frontal andlateral view!

2. Make a judgement of the skin covered with the tested compression. Indicate
whether the skin problem is absent (= circle 0), doubtfully present (circle 1) or clearlypresent (= circle 2)
Absent0

Doubtfully
present1

Clearlypresent2

1. Dryness

012

2. Local swelling(stagnation of fluid)

0

120

120

120120120

120

120

12012

3. General redness(e.g. evoked bycompression material,infection or sudden
increase of fluid)
4. Local redness(irritation due to highlocal pressure)
5. Strangulation(depression due to unevencompression)
6. Blister or vesicle(local accumulation offluid under the skin)
7. Erosion(loss of epidermis)

8. Ulceration(full thickness skin loss)

9. Papules(solid elevation of skinwith no visible fluid)
10. Other skin problem:(please indicate whichproblem):…

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Indicate the region withthe skin problem

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Appendix: reliable and valid quality of life questionnaires
General quality of life questionnaires
Short Form Health Survey 36 (SF-36)
Nottingham Health Profile (NHP)
Euroqol 5D (EQ-5D)

Disease-specific quality of life questionnaires
Lymphoedema

Upper Limb Lymphoedema 27 questionnaire or ULL-27 (Viehoff et al 2006)
Lymphoedema Functioning Disability and Health questionnaire for upper limb lymphoedema
or Lymph-ICF-UL (Devoogdt et al 2011)
Lymphoedema Functioning Disability and Health questionnaire for lower limb lymphoedema
or Lymph-ICF-LL (Devoogdt et al 2014)
Lymphoedema Quality of Life or LYMQOL questionnaire (Keeley et al 2010)
FLQA-l (Augustin et al 2005)
Lymphedema quality of life inventory (LyQLI) (Klernäs et al 2014)
Deep venous thrombosis
VEINES-QOL/Sym questionnaire (Kahn 2006)
Chronic venous insufficiency
Chronic Venous Insufficiency Quality of Life questionnaire (CIVIQ) (Launois 1996)
Tübingen Questionnaire for measuring Quality of Life in patients with CVI (TLQ-CVI) (Klyscz etal 1998)
Venous leg ulcer
Venous leg ulcer quality of life questionnaire or VLU-QoL (Hareendran et al 2007)
Health-related quality of life in chronic wounds or Wound-QoL questionnaire (Blome et al2014)

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