Compression Garments and Stockings for Leg Lymphedema
There are three broad groups of compression appliances we use in the treatment and mangement of lymphedema.
First are the compression bandages that are generally used during the treatment phase and that we wrap our legs or arms with each day.
Secondly are the compression garments referred to generally as compression stockings. After our treatments are complete and the limb is reduced as far as we can get it through MLD or CDT the next step is in wearing these compression stockings.
You can buy them “off the self” or have them custom made for your exact measurements. I personally believe the custom made type is the superior ones to use, even though they do cost a great deal more.
Below is a compilation of articles that go indepth on what these stockings are, why we use them, how to use them, the benefits and finally how to care for them.
We had a question in our Lipedema Yahoo group regarding which variety of compression garment works best, our always wonderful and brillant member Helen, a therapist from the UK posted this response. Thought I would share it here as well.
(Thanks Helen what ever would we do without you!)
You just know that Helen's got to stick her oar in with post! (see below). Red rag to a bull!
What a lot of confusing, contradictory information there is out there that is being given to those with lipoedema! I find it hard to believe.
I go back to my request for us all to be “singing from the same hymn sheet” as much as possible.
“Off the shelf” garments are just that - they are picked for you off the shelf. That means they haven't been made specially for you but will fit people whose measurements are within the range that that particular garment fits.
The problem with these garments is that for some people they might have, for example, a very small ankle, maybe a small knee, but a disproportionately larger calf. But if the calf size still fits within the range of the off-the-shelf garment (but at the top end of the measurement) and the ankle and knee are on the lowest end of the scale of the garment measurements, it will mean that that garment will have a looser fit at the ankle and knee, compared with the calf. And that has the squeezed-in-the-middle-effect of the long balloon that I wrote about last week.
The custom-mades however, are made specially for you, using your measurements. That means that if you have typical lipoedema (tiny ankle, bigger above in slight or large bulges) the garments can be made to fit your body. It won't fit anybody else's.
In terms of time, it depends if the therapist or pharmacy has these garments in stock if you are prescribed 'off-the-shelf' hosiery - if not then they still have to be ordered and I have no idea how long it takes for them to arrive (others on the site will answer that for you). I never order 'off the shelfs' - I only clear up the mess of those who do order them incorrectly for my clients… a long, frustrating story!!! Certainly I have had clients whose 'off-the- shelf' garments take 3 weeks to arrive. Not much of a 'service', if you ask me, and fairly useless, especially if the client has some lymphoedema present.
If you have custom-mades, they take 5 days from Germany, generally (Haddenham Healthcare garments). Your garment needs to be with you for when the intensive treatment (MLD and bandaging for 10 days +) finishes. I measure my clients on treatment day 5. The timing of the arrival of the garment is crucial for lymphoedema but I find it's not too serious with straightforward lipoedema, if it's late.
In terms of the fabric and ease of getting on…. it annoys me that people in need of good advice are not being given it. You should have been told that you need the appropriate compression fabirc for you. So the fact that an 'off-the-shelf- garment' might be easier to get on will relate to it being cheaper and of poorer quality. Yes, custom-mades might be a stronger fabric but - the same manufacturer will also sell a range of 'off-the-shelf' hosiery…and those garments will be in the same fabric as their custom-mades.
It's just that money rules. Therefore there are manufacturers around who supply to hospitals and surgeries where the NHS (in Britain) or insurance companies are obviously after a cheap option. And that affects the quality of the garment. But those same institutions are aware that as far as the population goes, as a whole, for 'the greater good', some compression is better than no compression.
But that doesn't mean that 'some compression' is enough for you! You are an indvidual with individual needs. You are not just a series of measurements - there is much to be considered. Your properly trained MLD (Manual Lymphatic Drainage) therapist should be able to advise you correctly.
However, there will always be some individuals who do happen to fit off-the-shelf garments (good quality ones - always check) and that is fortunate for those people.
I would always consider custom-mades first - as there is usually much better choice of fabric and colour. I would rather have a high proportion of cotton and the choice of 'without crotch' than a sweaty pair of tights that squeeze in the wrong places. But that's just me - I don't fit standard off-the-shelf compression.
Hope that is clearer than mud. I think a table woud be a good thing to put on here with examples of the off-the-shelf measurements for a typical manuafacturer. However, Yahoo doesn't seem to display them properly - I have tried in the past.
Have a good day Helen MLD therapist, UKIt's All in the Stocking
By Joy C. Cohn, PT, CLT-LANA, and Anne Lowry, MS, PT, CLT-LANA
Lymphedema management has changed dramatically in the United States over the past decade as health care professionals have trained in the European techniques known as complete decongestive therapy or complex decongestive therapy. The treatment of this chronic condition occurs in two phases. Phase one is generally intensive (1–5 days per week for 1–6 weeks) including manual lymphatic drainage, skin care, compressive bandaging, and remedial exercises. At the end of this intensive phase of treatment, when the limb has been “decongested” or reduced in volume, the patient is usually fitted with a compression garment to maintain the reduction. This commences the second (or maintenance) phase during which patients use self-treatment techniques as well as compression garments to maintain the reduction achieved in the first phase. Success in selecting and fitting the compression garment is essential to effective long-term control of edema.
External compression reduces ultrafiltration from the vasculature, enhances the musculoskeletal pump, increases the resorption of fluid into the venous and lymphatic system, reduces the local volume in the veins, and helps maintain the limb shape.1 During phase one, compression bandaging with low stretch bandages allows for a precise fit, readily adapting to the changing shape of the limb. However, bandaging is bulky, time consuming to apply, and unattractive. Garments offer considerably more freedom of movement in a more attractive form.CHOOSING THE RIGHT GARMENT
Selecting an appropriate compression garment is probably the most challenging task in lymphedema treatment. It is important to begin the discussion of garments early in the course of treatment. It often takes time for patients to adjust to the fact that they will need a garment. In many instances, patients must pay all or part of the cost of the garment, and they will need to plan in advance for the expenditure.
Important factors to consider when choosing a compression garment are: coverage, compression class, appearance, custom-made versus ready-made, material, construction, suspension, skin condition/sensitivity, donning/doffing, and cost and source of payment.
When considering coverage, preventing edema distally or proximally to the garment is important. During the decongestive phase of lymphedema treatment, the therapist will have learned whether, for instance, a bandage to the knee has caused an increase in knee or thigh volume. In that case, the patient will need a garment to the thigh or perhaps to the waist. Usually an arm sleeve will be accompanied by a separate glove or gauntlet to prevent trapping fluid in the hand. Some individuals never experience significant edema in the hand. If therapists back off on bandaging the hand during treatment and the patient does not experience any additional edema, this guides the decision as to whether to order a gauntlet, which just covers the back of the hand, or a full glove with edema control for all of the fingers. Some patients find they can even do without any hand garment, but in our practice, we always order at least a gauntlet since it is very difficult to predict exactly how every patient will respond.
Medical grade garments are available in various compression classes measured in millimeters of mercury (mmHg). These are standardized as:
Class I: 20-30 mmHg
Class II: 30-40 mmHg
Class III: 40-50 mmHg
Class IV: 50-60 mmHg
In a stocking, these numbers are the compression at the ankle with a gradually decreasing compression gradient to the top of the garment. Many ready-made stockings have a higher stretch fabric over the upper thigh called a mantissa. Even garments with the same fabric throughout will give lower compression over a larger diameter body part. Arm sleeves are generally Class I or II, and gloves and gauntlets are typically Class I. Lower extremity garments are generally Class II or III. Additional compression for the leg can be gained by using a higher compression class of garment or by layering a knee-high stocking under or over a longer stocking.
READY-MADE VS CUSTOM
Often the question of a custom-made versus a ready-made garment answers itself. Ready-made garments come in various girths, lengths, fabrics, and compression classes. They are made for a limb of average proportions, although some ready-made stockings do allow for an extra-wide calf and/or thigh. A patient with a disproportionate limb or who needs a higher compression class will require a custom garment.
Ready-made garments are less expensive, quicker to obtain, and easier to replace. They are usually made of relatively thin fabrics with few or no seams, making them cosmetically more acceptable to many patients. Their disadvantages are that they are less precise in fit, are more likely to roll at the top, and may not provide enough support.
Patients are always concerned about the appearance of the garment, particularly when the arm and hand are involved. Some garments are made only in beige, which has a medical connotation to some people, and which does not match the skin tone of darker-complected individuals. A garment may be ideal from a therapeutic point of view, but if the patient will not wear it for cosmetic reasons, it is useless. Sometimes the therapist has to choose a less effective garment that is acceptable to the patient. Some patients prefer a cosmetically desirable garment for public times, and a “workhorse” garment for sport or heavy activity.
Garments can be made of elastic or nonelastic fabrics. In general, the elastic fabrics are for daytime wear, while nonelastic ones can be worn day or night. Nonelastic garments provide compression by means of a series of hook and loop straps along the length of the garment. The wearer tightens the straps to the appropriate tension. Nonelastic arm sleeves and thigh-high leg garments are well padded with foam. They are comfortable, but too bulky for most daytime activities. Some lower leg garments are thin enough to be worn for walking. Nonelastic garments can be used in place of bandaging by patients who cannot bandage themselves.
The fibers used in elastic compression garments are generally latex rubber, synthetic rubbers, nylon, polyester, cotton, or a blend of these. Some are lined with cotton or silk for comfort. Fabrics can be thick or thin, depending on the fibers used and the amount of compression provided. In general, higher compressions mean heavier fabrics.
In selecting the fabric of an elastic garment, skin sensitivities are a paramount consideration. The compressive force in these garments comes from latex or synthetic rubber, so the therapist must know if the patient is allergic to latex. Most garments containing latex are knitted from a thread consisting of a latex core wrapped with nylon or cotton. A patient or helper at home who is severely sensitive to latex (eg, has a respiratory response to it) may not be able to use garments containing latex. Patients who have only a local allergic response may be able to wear them if an underliner is used.
There are three basic styles of garment construction: circular knit, flat knit, and cut and sew. Circular knit fabrics are seamless, but have a tendency to roll down at the top, especially if the area it covers is very fleshy. This creates a tourniquet effect, obstructing flow of fluid from the limb. In a flat knit garment, a flat piece of fabric is knitted to the patient’s measurements, and seamed up the back. These garments may roll less at the top. In addition, some flat knit garments are made of a coarse-textured fabric, which can provide a mini-massage to the skin, promoting improved fluid uptake and transport. A cut and sew garment is made of several pieces seamed together. More porous fabrics are cooler to wear, an important consideration for patient comfort.
To be effective and comfortable, the garment has to stay in place. Some will stay up by themselves. Some options are a silicone band inside the top edge or a few longitudinal (not circular) stripes of a clear body adhesive. For stockings, a garter belt, suspenders, or an extension of the garment to the waist are available. Arm sleeves can have extensions over the shoulder, which attach to a bra strap or a diagonal strap across the chest.
The condition of the patient’s skin will affect the choice of garment. Patients may have wounds or very fragile or sensitive skin. Pulling a tight garment over the skin can cause damage from shearing. In those cases, an understocking (even an ordinary thin nylon) will protect the skin, hold any wound dressings in place, and help the compression stocking slip on more easily. To decrease the friction of donning and doffing, custom garments and some ready-made garments can have zippers. Many patients ask for zippers in the garment. Zippers work well if patients have very narrow ankles or a paralyzed limb. We rarely recommend zippers because they do not eliminate the need to get the garment over the heel, they make the garment bulkier and less attractive, and many patients have difficulty closing the zipper once the garment is fitted on the limb.
For patients who need edema control for both legs, compressive panty hose can be difficult to don. An alternative can be a pair of thigh-high compression stockings with a compression bike pant over them. This arrangement is easier for most patients to manage, and is often more acceptable to men than a panty-hose style garment.
Compression garments are quite expensive, ranging in our area from about $50 for a pair of ready-made knee-high stockings to more than $500 for a custom-made waist-high garment. Some insurers will pay the supplier directly for the garments, some will reimburse the patient for all or part of the cost after the patient pays and submits a claim, but some insurers will not pay anything toward a compression garment. The only garments Medicare covers at present are stockings for patients who have been hospitalized with recurrent ulcers. Insurance plans differ widely and change frequently—another reason to open a discussion with the patient on reimbursment early in the treatment course.
Garments are ordered when the patient experiences a plateau in volume reduction, when the limb is not edematous, and in certain instances, for reducing the risk of developing lymphedema. Compression garments are very uncomfortable when applied to an edematous extremity, and they rarely produce significant reduction when used alone.2 Measurement for garments should be done as early in the day as possible, when the limb is at its smallest. Treating therapists usually do the measuring themselves, although nontherapist fitters can be used.
Contraindications to the use of compressive garments are:1,3 acute
infections/inflammation, cardiac edema, malignant lymphedema (relative), arterial disease, and acute vascular blockages (superior vena cava syndrome, acute deep venous thrombosis).
Extra precautions should be used in the case of: uncontrolled hypertension; paralysis; insensate limb; diabetes due to the high incidence of small vessel disease; and latex allergy (do not forget that the gloves used to don garments may have latex).
It is very important to educate patients in the proper use of their garments. We have seen many patients who have rejected garments in the past due to difficulty in donning or wearing them throughout the day but who successfully wear them with education. The education should include written and verbal instruction in don/doff procedures (including alternatives), care of the garments, and wearing and replacement schedules.
Donning and doffing are one of the major obstacles faced by many patients due to other conditions that limit their ability to reach their feet or to pull on a garment due to limited hand strength or pain. Rubber gloves and patience in applying the garment in stages are the hallmarks of success. There are several devices available from garment manufacturers that can help the patient get the garment onto the foot and over the heel or hand. These include frames to hold the garment open, slippery covers for the limb, and silicone-based products that make the skin more slippery. Cornstarch has also worked well for us. We avoid powders with talc due to the risk of skin irritation. Most garment manufacturers warn against the use of petroleum-based ointments because the fibers (especially latex rubber) can be weakened by exposure to these products. When patients require a higher compression class than they are able to don easily, we will try layering the garments to achieve effec-tive control.
All garment manufacturers recommend replacement of the garments every 4 to 6 months. The actual interval is based on considerations such as wear due to use, severity of the edema, and type of fabric. Many patients buy two garments to have one to wash while the other is worn. Garment manufacturers include care instructions with their garments. In all cases, we recommend daily washing by hand with mild liquid detergents (for example, Ivory or Dreft) and squeezing gently in a rolled-up towel and hanging to dry.
Finally, patients are encouraged to don their garments as soon as is practical in the morning, when the limb is at its smallest. Many patients alter their lifestyle to shower in the evening so they can don their garments over dry skin first thing in the morning.
Given the long-term use of garments by most lymphedema patients, it is imperative that the treating therapist give a great deal of thought to choosing the appropriate garment and educating the patient in its use. This is crucial to successful treatment of patients with a chronic condition.
1. Casley–Smith JR, Casley–Smith JR. Modern Treatment for Lymphoedema. 5th ed. Adelaide, Australia: Lymphoedema Association of Australia; 1997:174-175, 178. 2. Johansson K, Lie E, Ekdahl J, Lindfeldt J. A randomized study comparing manual lymph drainage with sequential pneumatic compression for treatment of postoperative arm lymphedema. Lymphology. 1998;31:56-64. 3. Hohlbaum GG, ed. The Medical Compression Stocking. New York: Schauttauer; 1989:56. Joy C. Cohn, PT, CLT-LANA, and Anne Lowry, MS, PT, CLT-LANA, are certified lymphedema therapists in the lymphedema treatment program at Chestnut Hill Rehabilitation Hospital in Wyndmoor, Pa.
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