Sunday, November 23, 2008

About Leg Lymphedema Sleeves and Garments

About Leg Lymphedema Sleeves and Garments

Most people do not know what lymphedema is until they have it. Once diagnosed they are shocked and concerned about what to do. There are several different options for the treatment of lymphedema including various kinds of compression garments. They often are recommended to prevent swelling when flying on an airplane. The Ted Mann Family Resource Center at UCLA has pamphlets on this topic. There are a few people around the country that specialize in this treatment.

Many patients will be prescribed garments that will provide compression for the affected limb. The garments help to keep fluid from accumulating in the limb. These garments have specific amounts of pressure and can be worn on the legs, hands, feet, or arms. The garments are made of a tight stretchy fabric. An expert fitter must fit lymphedema garments (sleeves).

Measurements are taken, and a patient must try on the sleeves to make certain that they have a comfortable fit.

Sometimes custom sleeves must be made, but most people are able to find a pre-made sleeve in a suitable size. The sleeves prevent the accumulation of more fluid in the limb; they do not pump fluid out of the limb. The garments are usually used in combination with therapy or as a preventive or maintenance measure. Lymphedema sleeves and treatment can change the size of the affected limb as can various activities. Sometimes patients need more than one sleeve during this process because of the changing size of the limb. There is a tendency for patients to think that their sleeve has been fit improperly. Sometimes it has been, but more often than not, the limb has changed in size.

Note these sleeves wear out with continued daily use and must be refit and replaced on a regular basis (approximately every 3-6 months). Over time with washing and wearing they lose their compression. Different levels of compression are used for prevention versus maintenance.

For individuals with more severe or chronic lymphedema, Reflections carries two products that help to move fluid from the extremity, therefore, having a therapeutic effect. These two products are called CircAid and the Reid Sleeve. They are both custom made for the patient.

Do I need a prescription for a lymphedema garment?

Yes, a prescription is needed even for a prevention sleeve. Your doctor or nurse practitioner may write your prescription. A typical prescription for a lymphedema sleeve reads as follows:

“Compression garment for (leg, arm, hand, foot) (right, left, bilateral), for (diagnosis - type of cancer or other condition). Compression of (amount of pressure to be specified by doctor).”

Even if your insurance company does not reimburse for the cost of these products, a prescription from your doctor will allow you to purchase the item without paying sales tax. Your doctor may fax the prescription directly to Reflections (310-794-9088) and we will hold it until you come for your fitting.

Will lymphedema garments be covered by insurance?

Medicare does not cover the price of lymphedema garments; however, many other insurance plans do. It is important to talk to your insurance company to determine whether these are covered items and what kind of authorization may be needed. Your doctor may be required to provide a medical justification for your compression garment in order for your insurance company to reimburse for the product. Many doctors do not fully understand these sleeves, how they work or what may be required by your insurance company. Talk to your doctor about these issues at the time your referral is made. Inform them that you may need a letter justifying the need and that they may need to provide this on an ongoing basis as your garment needs to be changed or renewed.

What are the prices of these products?

The products vary in price. Those that are custom made are more expensive than those which are stocked as part of our regular inventory. The following listing will provide an approximate idea of the range of prices for these products. The most important concern is to obtain the best product for your particular condition, which should be assessed by the physician/treatment team who is involved with the care of your lymphedemagarment.

Cancer Resources

Compression Garments for the Treatment of Lymphoedema

by: Judith R. Casley-Smith & J.R. Casley-Smith (L.A.A., University of Adelaide)

Compression garments and compression bandages, are probably the most difficult problem we have had in the maintenance and control of lymphoedema before, during and after treatment. These are not yet completely solved. However the situation is a great deal better than it was in 1987 in Australia , when we introduced Complex Physical Therapy (C.P.T., Complex Lymphatic or Lymphedema Therapy - C.L.T.). They are absolutely essential for maintaining the great reductions achieved by this combination of treatments.

Compression garments are necessary

1. to prevent lymphoedema occurring or increasing,
2. to try to maintain the size of the limb when treatment is unavailable or unaffordable,
3. to maintain the reduction achieved after treatment, and to continue the remodelling of the limb.

1. Prophylaxis - Prevention of Lymphoedema

If a limb is a risk (e.g. after a mastectomy, operation for melanoma, etc.) then a correctly fitting garment should be kept on hand for immediate wearing, e.g., after an injury, during an aircraft flight (even for just one hour!), or excessive work causing aching and leading to swelling, etc. Prevention is of the utmost priority, because it is much easier to prevent lymphoedema than to treat it! However the garments in this situation should be no more than 30 mm Hg for arms and 40 mm Hg for legs (much higher pressures can, and should be used after a course of C.P.T.

2. Garments used as the only Treatment

If no other treatment is used, good compression garments will limit the amount of swelling and thereby slow the advancement of lymphoedema. Some patients even get reductions in their limbs using just such garments and the L.A.A. exercises. However, this is far from the ideal. Again, the pressure must be less than if the limb had been reduced with (C.P.T.).

3. After Therapy

For reasons already mentioned, these are essential after C.P.T. If patients do not wear and maintain garments correctly they just throw time, effort and money away!

The Choice of a Garment

Availability is almost as important as efficacy. There is no point in treating a patient by C.P.T., and then having to wait weeks for a suitable garment to arrive. A patient, alone, is often not able to bandage themselves as is done in the clinic (especially post-mastectomy patients). In fact it is hard enough for some to put on a pressure garment. This means that the choice of appropriate bandages and sleeves/stockings depends very greatly on good suppliers. If the garment has to be custom made, it is helpful to have a local seamstress who can do any fine alterations necessary. (However if this is done the garment guarantee is often invalidated.)

Once a therapist is experienced, they find that almost all of the reduction occurs in the first 7-10 days. When they are confident of this, a suitably-fitting garment may possibly be ordered at this point if a made-to-measure one is required. In this regard, it is essential that measurement of the patient in the clinic or by a supplier is done absolutely correctly. Mistakes can be made, but it should not be the patient who has to bear that cost.

Choice is also limited by whether a patient can actually be fitted with a ready-made garment, or whether they need a custom-made one. Children and many patients with primary lymphoedema can only be fitted with custom-made ones. Use of a regular (standard) garment is advised if the patient correctly fits the measurement parameters. This overcomes the possibility of mistakes in the size or fit of a made-to-measure garment; it is also cheaper. We stress that the regular garment must fit correctly and comfortably. However a made-to-measure garment may be still more comfortable to wear.

The quality of the fabric is also important. These garments must last at least 4 months. They need to be changed and washed daily, especially in a hot climate. Patients must follow the manufacturer's washing instructions and should never allow them to dry in the sun or in a drier. Jobst-Beiersdorf supplies Jobst 'Jolastic' a special washing solution for elastic garments, but there are other suitable mild detergents.

Patients must be shown how to put on the sleeve/stocking so as to cause minimum stress on it. Rubber gloves with a raised pattern on the finger tips should be used. (Sigvaris supply these, or certain washing-up gloves are suitable.) Such gloves will:

protect the garment from fingernails, rings, etc., make them easier to get on, allow the garment to be adjusted evenly over the limb and fit it correctly.

Care must be taken in the use of skin preparations when wearing a garment. Although some have been recommended for use under garments (Com-pat Body Lotion - Jobst), the manufacturers do not guarantee that they will not affect the life of the garments. Of course wearing a bandage at night allows suitable skin care products to be used easily.

We also stress the importance of skin care. Be aware of the list of products from Hamilton Laboratories and from certain other manufacturers. Particularly recommended are: Hamilton's Body Wash, plus Shower Oil as a moisturiser. These are much preferable to soap for lymphoedema. Other useful products are: Dimethicream or Skin Repair for general moisturising, Urederm for the treatment of chronic dry skin and Dermex 7A as a protection and moisturiser while swimming or during hydrotherapy in pools. Castellani's Solution can be used on any moist 'folds' (ask your pharmacist for it); 'Minidine' also works well. Remember protective sunscreens. Lodema (coumarin) powder is very good under a garment. Lodema (coumarin) ointment can however only be used under bandages or if a garment is not used at night; it is also good for bites, stings cuts, burns or bruises.

The comfort, and therefore the patient's compliance, is of great importance for maintaining the gains made during therapy. Hence much depends on the fit of the garment and the material used.

Some patients have allergy problems to synthetic materials and a cotton coating of the elastic fibres is then very important. Some garments 'breathe' more than others, giving greater comfort and compliance. A new garment may cause pressure or irritation at a joint or under the arm; a lining in the garment at this point or powder or a smooth adhesive dressing (e.g. 'Fixomull', Jobst) may alleviate this.

It is useful for the patient to wear the garment for the last few days of treatment so that all the above problems can be checked. It will also give a good indication as to whether the compression is adequate. If not, a second, lower grade, over-garment will be needed also.

A number of patients need gloves or mittens. The gauntlet variety (i.e. attached to, and part of the sleeve) are preferable in that they reduce the risk of a pressure band at the overlap. This is difficult with a stocking. Separate bandaging of the toes and distal part of the foot may be needed.

Garments should be able to be worn easily and stay in place without slipping. A woman with a prosthesis often cannot maintain an arm sleeve in place with a support strap attached to her bra strap on that side. It may be more comfortable to wear a chest garment incorporating a bra and sleeve, joined with a slit under the arm to allow for breathing and perspiration. A wide strap around the chest below the other breast may work.

Many bands used on garments are too narrow to be comfortable and need to be replaced by something wider. Similarly, a waist band to support a leg stocking may slip - allowing the stocking to slip down. In this case a pantyhose arrangement, with one leg cut off (if only one is lymphoedematous) and a slit at the crutch, feels more secure and a lot more comfortable.
After a mastectomy a well fitted bra should always be worn. The straps should not cut into the shoulders, nor should wire under a cup cause red lines or indentations. These will both restrict lymphatic drainage. Realize that the opposite breast is also 'at risk' of swelling due to overloading of the natural collateral drainage. Similarly with a lumpectomy plus radiotherapy, the breast on which this was performed is also 'at risk' and should be properly supported.

There are solutions available which have been specially made to stick the garment to the limb (e.g. 'It Sticks!' from Jobst and 'It Sticks' from Sigvaris). These must be used with care and applied as a number of vertical stripes. If they are applied horizontally in a ring around the limb, they can shrink as they dry. They pull the garment with them and so cause a band of excess pressure at the top of the limb, which will restrict lymphatic drainage. So be careful!

One needs to be wary of a stocking or sleeve that stops too short of the top end of the limb, or that causes a pressure band at that (or any other) point. This will reduce lymphatic drainage as well as causing a band of fibrous tissue to form which also later reduces this.

Patients also need to be aware of the amount of exercise that they should do. If too much is attempted, the limb will swell further; then the garment becomes uncomfortable. The patient then feels it is too tight and so takes it off, then the limb swells still further and a new garment is required of a larger size! Some patients also like to remove their garments for long periods of time (e.g. at night). Then the limb again swells and the patient feels that the garment was the wrong size and may wrongly blame the clinic or the supplier!

These principles also apply to the treatment of acute injury and to oedemas (usually lymphoedemas) caused by paralysis or confinement to wheel chairs.

Similarly, venous oedemas (including chronic venous insufficiency and during pregnancy) should be treated with compression stockings, but of a lower grade (18 - 48 mm Hg is usually recommended by the manufacturers and therapists).

Patients with a lympho-venous shunt, diabetes or arterial insufficiency can only tolerate a garment with a lower pressure than usual. This also applies to untreated patients.

If a patient finds it too difficult to put on a high compression garment, then two lower compression ones - on top of each other - may be preferable. But a 40 mmHg plus a 30 mm Hg one do NOT give 70 mm Hg, but approximately 55 mm Hg.

For lymphoedema of the leg, unlike for chronic venous insufficiency or varicose veins, a full thigh-high stocking is essential to prevent just pushing the lymphoedema above the knee. In venous oedema, a calf stocking of lower pressure is sufficient unless lymphoedema is also present.

When choosing a garment or sock, it is very important that it does not cause constriction just below the knee - thus preventing drainage and leading to swelling. Some socks are not long enough for taller people and slip when walking; if so, get one that comes to mid-thigh (which will also alleviate the problem of a 'tourniquet' effect below the knee.

Good communications and suggestions between the patient and therapist, and between the therapist and the supplier are essential to provide the best possible service for the patient. Pressure sometimes needs to be applied to the manufacturer to actually supply the patient's need and thereby to give an efficient service. A patient with problems should always return to their therapist. Analgesics should never be taken just to overcome constant pain from an ill-fitting bandage or garment. Manufacturers try hard to accommodate customer requirements, but need feed-back to understand.

An excellent book for for doctors and therapists who wish further more detailed information is: Hohlbaum GG. The Medical Compression Stocking. Stuttgart & New York, Schattauer, 1989.

Vital Points on Compression Bandages and Garments

Treatment for lymphoedema is a continual process. It is not cured by one course of treatment. While a therapist can reduce the swelling initially, the patient is responsible for maintaining that reduction. What follows are a few simple rules, all are vital!:

1. The bandages or garments must be worn all day and all night.

2. Each set of bandages, or a garment, must be changed and washed at least every couple of days.

3. Care must be exercised when putting on bandages or garments.

4. Bandages or garments must be replaced if they lose elasticity or are damaged.

5. At least two sets of bandages or garments must be owned.

6. Order a new garment well before an old one has worn out.

7. The manufacturer's washing instructions must be followed and they must not be dried in the sun or in a drier.

8. The therapist must be consulted if a limb becomes painful or discoloured (e.g. blue toes), or if a garment chafes or is too loose or too tight.

9. Nights are more restful if the patient changes bandages or garments before sleeping.

10. Wash the limb thoroughly when changing bandages.

Lymphoedema Association of Australia

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