CLINICAL DEVELOPMENT The use and benefits of compression stocking aids

Author Ann Dilks, DIP, COT, is senior occupa- vein thrombosis (DVT) (Amaragiri and Lees, 2003). tional therapist, Derbyshire Equipment Advisory In-hospital antiembolic stockings are used before Service; Judy Green, DIP, COT is senior occupa- and after surgery when patients are immobile. tional therapist, Derbyshire Equipment Advisory Compression/surgical stockings are also pre- Service; Sue Brown, MSc MCSP, is research ergon- scribed for longer periods of time to manage leg omist, ATEC Derby City General Hospital. ulcers and oedema. There are different regimes for Abstract Dilks, A. et al (2005) The use and wearing the stockings but in the community there benefits of compression stocking aids. Nursing must be the opportunity for stockings to be put on References Times; 101: 21, 32–34. and taken off when required, and for washing and An exploratory study was undertaken to trial replacement when necessary. Amaragiri, S.V., Lees, T.A. (2003) Elastic various stocking aids designed for use with com- compression stockings for prevention of pression and antiembolic hosiery. Their features Application deep vein thrombosis. Cochrane were identified and assessed by professionals for Putting on stockings can be difficult for users with Review. Available at: www.update- software.com/abstracts/ab001484.htm ease of use. Factors affecting the choice of stock- physical limitations such as restricted range of ing aids were the style and grade of stockings movement and reduced muscle power, making The CLOTS Collaboration (2005) and the physical ability of users. bending forward or lifting their leg a problem. In Summary. Available at: addition, compression stockings require a lot of www.dcn.ed.ac.uk/clots/ Occupational therapists working at a community stretching to put on and users with reduced equipment service demonstration and advice cen- strength in their hands may not be able to achieve tre were prompted to find out about stocking aids this. Stocking aids aim to help users put the stock- as a result of an increasing number of enquiries ing over their foot and ankle and pull it up the leg from patients, carers and professionals concerning by eliminating the need to bend forward. devices for applying surgical stockings. A second Without the ability to put on and take off stock- reason behind the move was the decision of social ings independently the user would have to keep services to withdraw permission for its staff to them on over more prolonged periods of time or put on surgical stockings due to the risk of inap- require frequent assistance from family carers, propriate application. nurses or care services. As a result of these changes district nurses be- Correct provision of support hosiery applicators came responsible for applying surgical stockings to or aids promotes the independence of individuals patients in the community (for the purpose of this who are unable to flex at the hip and people who article the terms compression/surgical stockings have had hip replacements and are advised not to will be used to describe all types of stockings, in- flex beyond 90º to avoid the risk of dislocation. cluding thromboembolism hosiery and graduated compression hosiery). Fig 1. Cloth stocking aid Effective use of compression/surgical stockings, including patient compliance, has cost implications in both the long and short term regarding assess- ment and reassessment of need, use, replacement and fitting. The question was also raised asto whether putting on compression/surgical stock- ings is personal care or a medical procedure.

Usage Compression/surgical stockings are used as part of a patient’s treatment and require the user to wear them for a specified period of time. They apply graduated pressure to the legs to help improve ve- nous return. These stockings are prescribed for a variety of reasons including the prevention of po-

tentially life-threatening conditions such as deep SPL

32 NT 24 May 2005 Vol 101 No 21 www.nursingtimes.net keywords n Compliance n Compression stocking aids n Prevention

Fig 2. Gutter stocking aid applied at the ankle, class I being the lowest and References class III the highest. Non-prescription compression hosiery may be manufactured to other standards Department of Health (2005) Drug and specifications, for example European guide- tariff: National Health Service lines. Although they are identified as class I, II and England and Wales. Norwich. The Stationery Office. III the pressures they apply differ from the drug tariff specifications. Nelson, E.A. et al (2005) Compression A trial is currently under way to establish the for preventing recurrence effectiveness of compression stockings in the pre- of venous ulcers. (Cochrane Review) vention of DVT and pulmonary embolism after The Cochrane Library. Issue 3. stroke. The study also aims to determine whether Oxford: Update Software there is any difference in the effectiveness of above-knee and below-knee graduated compres- Hanson, E. M., (2004) Usability test. sion stockings in reducing the risk of DVT (The Hjealpemidlet; 2: 4–7. CLOTS Collaboration, 2003). Methods With a view to having a supply of compression/ Findings surgical stocking aids in the community equipment In general it was hard to gather information about store, for loan or sale, the first task was to identify the number of products available. For example, products on the market. Searches were carried out different distributors give the same product a dif- to identify what products were on the market us- ferent name. Although some products were for ing the Disabled Living Foundation catalogue, the use with specific types of compression stockings, internet, company catalogues, telephone calls to consultation with the various companies identified specific companies and discussions with members that they seemed to be unsure which of their of an equipment interest group. A search of recent products could be used with compression/surgical literature was also undertaken to find information stockings or ordinary stockings. This discovery regarding the use and effectiveness of aids. highlighted the various features of different styles All the companies contacted were asked to loan and grades of garments. samples of their products for user trials. The equip- ment interest group, comprising occupational ther- Assessment and issue of stockings apists, district nurses and other interested clini- Stockings are issued according to leg measure- cians, had indicated an interest in the investigation ments, which should be given by the prescriber. and agreed to try out the products at one of their The length and circumference of the leg are need- meetings. A questionnaire was designed for feed- ed to select the correct size. Above-knee or below- back on each aid they used. knee style should be specified and the stockings come with either open or closed toes. Consent Information from pharmacists indicates that Before trying out the stocking aids the 13 mem- there are often insufficient details on the prescrip- bers of the group gave their consent for their dis- tion to identify the size required. In addition, phar- cussion and questionnaire data to be used when macists do not have facilities to measure individu- the findings were reported. als, and it is not always the patient who takes the In accordance with research governance, partici- prescription to the chemist. pants were assured of confidentiality and remind- A patient in need of made-to-measure hosiery ed that involvement was voluntary. Ten stocking often does not receive it as the details are not aids were available and the users logged their completed on the prescription. There is also varia- opinions regarding features and the ease and ef- tion between services as to the provision of stock- fectiveness of use. ings and applicators.

Stockings Education and compliance Antiembolism hosiery, otherwise known as TED If people do not understand the purpose of the stockings, is only issued by hospitals. They are in- stockings they may think they are the wrong size tended for non-ambulant patients during and im- as they feel too tight. This has implications for mediately after surgery. Graduated compression compliance as having ill-fitting stockings is the hosiery is intended for mobile patients and is main reason people give for not wearing them This article has been double-blind available on prescription. (Department of Health, 2005). peer-reviewed. Prescribed hosiery fulfils the drug tariff specifica- Conversely if stockings become loose due to re- For related articles on this subject tions, which list three classes of compression ho- duced swelling or long-term use then they are not and links to relevant websites see siery. The classes indicate the amount of pressure fulfilling their intended purpose. www.nursingtimes.net

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Fig 3. Frame stocking aid whether or not they are the right size and whether or not they are aesthetically acceptable to the user. Feedback from the district nurses and occupa- tional therapists was summarised and they high- lighted features of the products they thought were good or problematic. Positive comments for the frame and gutter aids included: l Reduced need for the user to bend; l Stretches the stocking for a foot to be put in; l Ease of pulling up the stocking; l Stable when standing on the floor. Negative comments about frame styles included: l Difficulty getting a stocking onto the aid; l Help needed from a second person or aid, for example ‘helping hand’; l User needs to be agile; l User needs to have good hand function; l Lack of size adjustment on the aid; l When available, instructions were poor.

Discussion This exploratory exercise identified a number of is- sues that need further study, relating to compliance User compliance was influenced by: of patients who are prescribed compression/surgi- l Understanding of the actual need to wear the cal stockings and the use of stocking aids among stockings or compression aids; these patients: l The type and grade of stockings issued; l The effectiveness of compression/surgical stock- l Whether they were full leg or half leg. ings (Nelson et al, 2000); Stronger grades and full-leg stockings are more l The grading of compression/surgical stockings; difficult to put on and may well mean the patient l Prescription and the issue of whether patients will not or cannot wear them. Also, patients may receive the correct size of compression/surgical not like the look of the compression hosiery, par- stocking when dispensed; ticularly if they like to wear skirts or dresses. l Assessment of compression grades for comfort and ease of putting on and removing; Stocking aids l The physical ability of the patients to use Three styles of stocking aid were identified among the stocking aids; the products tested. These were the same styles l Users’ feedback on compression/surgical stock- as compared in a Danish study (Hansen, 2004). ings and stocking aids; l Fabric, which made it easier to slide the foot l The compatibility of compression/surgical stock- into the stocking and pull the aid out of the stock- ings and stocking aids; ing – for use with open-toed style only. This design l Users’ and health care professionals’ percep- did not eliminate the need to bend (Fig 1). tions of compression/surgical stockings as a part l Gutter, which stretched some lower grade stock- of treatment. ings making it easier to put the toes into the stock- ing. Tapes or ropes were attached to pull the aid Conclusion and stocking up the leg, to reduce the need to Being able to put on compression stockings is cru- bend over 90º (Fig 2, p33). cial for people with conditions such as DVT. The l Frame, which could stretch all stockings to make provision of aids to help with patient compliance is it easier to put the foot in, some frames had han- a vital part of this treatment, especially for those dles to help pull the stocking up without bending with mobility problems, for example following hip or flexing the hip more than 90º (Fig 3). replacement surgery. It is important to ensure that The choice of stocking aids is dependent on the patients have the most effective type of stocking abilities and limitations of the user and the fea- aid for their individual needs. tures of the stockings. Being unable to put on com- This study identified a number of areas and ways pression stockings may be only one of the reasons in which patient compliance could be improved. It for non-compliance. is important that more studies are carried out in Other reasons include users being unaware of this area to further improve the provision of evi- the importance of wearing compression stockings, dence-based care to this client group. n

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