Practice development

Compression garments for managing lymphoedema

Robyn Scheer

Key words Abstract

Compression garments, lymphoedema Lymphoedema is a chronic condition due to a compromised lymphatic system and results in the accumulation of oedema. It can affect patients who have undergone cancer treatments that involve removal of lymph nodes and radiotherapy. It can also present from a congenital defect Robyn Scheer is an Occupational Therapist – Advanced of the lymphatic system and as a complication of a venous disorder or filarial infection. The Lymphoedema, Royal Brisbane and Women’s Hospital, author has over 20 years’ experience working with lymphoedema patients and has a particular Queensland, Australia interest in compression garments. In this article, best practice and the author’s accumulated clinical knowledge are shared. Australia experiences some unique challenges, but many of the Declaration of interest: None. difficulties discussed are shared internationally.

urrently, most treatment options The issues that arise when prescribing manufacturing techniques commonly for lymphoedema manage, compression garments include: employed are circular knit, flat knit, and rather than cure, the condition. • Comfortable fit cut-and-sewn (Figure 1). CInternationally-researched treatment • Adequate graduated compression to options are often multifactorial, such as manage oedema Circular knit complex lymphoedema treatment, which • Acceptable design for the patient’s The circular knitting machine includes patient education about the lifestyle manufactures a long tube of fabric to condition, exercise, weight management, • Wear regimen produce quite a sheer, soft, stretchy and skin care, specific massage, compression • Manageable cost smooth fabric. These characteristics bandaging if indicated, and maintenance • Management of replacement garments. can make the garment more appealing; with medical compression garments however, the fabric lacks stiffness, rests (Lymphoedema Framework, 2006). In Fabrics and firmness in skin creases and may roll more easily 2012, Mosti and Partsch showed that Compression garments are manufactured at the proximal end. Benefits include the compression stockings could be as effective internationally for many different medical fact there are generally no seams unless a as bandaging in reducing oedema if the size of conditions. Australia has a relatively small band is attached, the fabrics can be dyed in the stockings was changed to match the limb population of 24 million (Australian a variety of colours and circular knits come size reduction. Other treatment modalities Bureau of Statistics, 2016) and relies on in ready-to-wear ranges and a limited range including low-level light laser, intermittent industry partners to import and distribute of custom made sizes. pressure devices, Kinesio Taping® and many of the compression garments liposuction require a medical compression required to treat lymphoedema. This Flat knit garment to maintain any reduction achieved condition can require lifelong treatment This is manufactured as a flat piece of (Lymphoedema Framework, 2006; Ridner with compression so it is important to fabric and then constructed and sewn into and Sheila, 2013). correctly prescribe and fit compression the desired shape. It is a thicker and stiffer Recently, the benefits of manual garments. Most companies provide fabric than circular knit. A seam is required lymphatic drainage massage as a stand- brand-specific training, which can be a to construct the garment, which can be a alone treatment have been questioned valuable way of accessing information weaker point in the design. Generally flat and the vital role of compression therapy about products, correct measurement and knit garments are sturdier than circular confirmed (Nikolaidis et al, 2015). Many treatment options. knit or cut-and-sewn garments. Both authors, including Todd (2015), describe There are a range of ready-to-wear ready-to-wear and custom-made garments compression hosiery as the “cornerstone of sizes and lengths. Compression garments are available in these fabrics, and they are management of chronic oedema”. can also be custom made. The three particularly suited to larger shapes.

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Figure 1. The three types of compression garment fabric (left to right): flat knit, round knit and cut-and-sewn.

Cut-and-sewn garments are marketed by manufactures garments when necessary to maintain the Here, a stretch fabric is cut and sewn into as being suitable for a particular diagnosis, benefit of compression. the shape required. There is great flexibility but in clinical practice selection is often in the designs that can be used. There are more complicated than this. Insufficient Garment lifetime several drawbacks to these garments: they pressure will not manage oedema and Washing, sun, body oils, perspiration and often require zips for closing and have excessive pressure can be intolerable for stretching from donning and doffing, multiple seams that can be horizontal or the patient, cause pain on pressure points as well as the wear and tear of life affect vertical, which may cross the path of the or be too difficult to don. compression garment fabrics. The lymphatic flow. The fabrics vary in stiffness Patients and therapists need to be aware compression garment will not provide the and can be lined if frail skin is involved or that once compression garments have been required compression once damaged by the garment passes over a vulnerable joint, worn and washed, the compression values these factors. such as the elbow crease. cannot be guaranteed. The patient and The majority of manufactures recommend prescriber need to monitor and replace that if garments are worn daily, washed Firmness The firmness of the fabric on the skin is measured in mmHg and is specified Table 1. Differences in compression standards (Todd, 2015). by a variety of standards (Table 1). Compression standards have been Class British standard French standard German (RAL) standard developed to ensure quality medical I 14–17 mmHg 10–15 mmHg 18–21 mmHg compression garments are available on the market. II 18–24 mmHg 15–20 mmHg 23–32 mmHg Clinical decision-making is required to III 25–35 mmHg 20–36 mmHg 34–46 mmHg determine the most appropriate value for IV N/A >36 mmHg >49 mmHg a particular person. Many compression

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Box 1. Issues to consider when prescribing compression garments.

• Obesity: body shape will dictate whether ready-to-wear options are possible • Mobility: reduced mobility will impact on lower limb oedema • Reduced range of movement: upper- limb restrictions will increase the risk of oedema and impact on ability to don compression garments • Hand dexterity: restricted hand movement will impact on ability to don garments • Occupation: a patient’s job, eg nurse or child carer, may not be compatible with compression • Caring responsibilities: eg caring for older people or young children • Comorbidities: conditions such as arthritis or diabetes can limit tolerance to compression • Pain: significant pain can reduce tolerance of compression • Age: children and frail older people have particular needs • Cognitive impairment: inability to follow directions regarding the wear or Figure 2. The lymphoedema compression garment decision tree. care of compression could mean a carer is required for safe application Issues to consider in patients arm measurements will be significantly • Personal preference: this is crucial to with lymphoedema larger than the wrist. A silicone band finish patient adherence Assessment, education, wear and care can reduce rolling at the axilla and style • Finance: compression garments are A face-to-face assessment with the options, such as shoulder caps and extra- expensive and subsidies may or not be patient is important and time needs to wide bands, reduce the risk of rolling at the available to assist with the cost; personal be taken to consider options, fabrics, proximal end in such patients. The elbow and/or public funding will impact on the styles, compression levels, and to educate can be problematic, as any joint will put choice of garment available the patient about wear and care of the extra stress on the fabric with movement. compression garment. Time invested When oedema involves the hand, this • Geography: eg in Australia, time and at this stage is well spent, as an ill- can be very restrictive for a patient as a full distance need to be factored into fitting compression garment will not be glove may be required. Gloves can cause prescription. tolerated, risks creating further oedema problems with personal hygiene and are problems and wastes limited resources. incompatible with some occupations. regularly, and there are two sets to alternate, Issues that may need to be considered they should last 4–6 months. This is only when prescribing compression garments Choosing a lower-limb style a guide and will vary from individual to are given in Box 1. The process is Oedema accumulation in the lower limbs individual, so the best advice is to monitor summarised in Figure 2. can be significantly impacted by gravity the garments. Patients who are regularly in and reduced mobility, as the muscle pump contact with a healthcare professional will Choosing an upper-limb style will not be working as effectively. The key often be assessed every 6 months, and this It is important to look at the whole limb principles of compression are (Wounds is when garments can be replaced. and consider whether the hand or wrist International, 2013): It is vital to educate patients that is involved, as well as the arm. A simple • To counteract the force of gravity and compression garments will overstretch and axilla-to-wrist sleeve with a variety of promote the normal flow of venous roll if not washed daily or on alternate days. finishes and fixation options at the axilla blood up the leg The washing process causes the fibre to can be used for an upper limb. If the • To improve venous and lymph return return to its original size. patient is overweight or obese, the upper and reduce oedema.

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to ease donning, eg a below-knee over a some patients or their carers to don/doff, thigh-length can add extra compression at particularly with a large limb. Velcro wraps the extremity when required. are bulkier than regular compression It is important to consider where the garments and need a significant level of accumulated fluid will be directed. If it is in skill to ensure appropriate compression the thigh, for instance, will it be redirected is applied, however, and these issues to the genital area and bike pants may will need to be considered if they be indicated. are prescribed. Another consideration is the addition When compression should be worn of zips to custom-made compression Determining when compression should garments. These can be useful for removing be worn needs to be considered on an garments, but require significant manual individual basis and should be discussed by dexterity when donning. Figure 3. An example of an ill-fitting the patient and prescriber. Compression A final consideration is whether the compression sleeve requiring urgent garments are typically worn during the day, patient can engage the assistance of family replacement. when the limb is in a gravity-dependent members or community carers. As this position. A compression garment can be is usually a twice-a-day, 7-day-a-week washed in the evening and dry overnight, obligation, it can be challenging for a ready to be refitted in the morning. In patient to arrange. cooler months, it can be dried in front of a fan, but not in a drier as the heat damages Financial issues the fabric. If two or more garments are Financial support towards the cost available, wear can be rotated. Patients of compression garments varies from with particularly challenging oedema may state to state in Australia. A survey of need to wear compression at night and Australasian Lymphology Association should have at least two garments to allow members reported that 46% of cleaning and rotation. practitioners had compromised on Many patients are concerned about how compression garment prescription due to they will manage compression garments in financial constraints (Scheer et al, 2006). the summer, as it gets very hot in Australia. Financial constraints have been reported Encouragement and simple practical as a concern internationally (Shih et al, approaches, such as keeping cool with fans 2009). Patients with lymphoedema who or air conditioners in the heat of the day, have private health insurance may have reduces the discomfort for many patients access to some financial support, but with lower levels of oedema. the rules for each policy vary greatly and Figure 4. Examples of assistive devices. change from company to company. It is From left to right: rubber gloves, Ezy-As Other potential challenges recommended that patients investigate (Ezy-As ABC), Easy Slide (Arion), donning Lymphoedema is a chronic condition and their eligibility prior to committing to frame. patients may present for treatment some expensive garments if they are relying on years or months after an unsatisfactory financial support. prescription for garment compression. Patient lobbying has been the most Toe involvement may necessitate toe Patients prescribed ill-fitting garments powerful tactic to date in successfully pieces, which can be worn with open or (Figure 3) or not provided with gaining government funding support closed toe styles. Open toe pieces may feel information regarding where or when for compression garment subsidies in cooler, but they have a tendency to ride up they were to replace the garment may have Australia (Queensland Health, 2014; the foot, allowing accumulation of fluid on no confidence in compression therapy. Mercy Health, 2015). However, the the dorsum. Encouraging suitable shoes, Careful prescription and education variation in subsidies and the limiting such as a lace ups that can accommodate regarding wear and care of the garment rules across the country continue changes in size, will increase compression is required to build trust and confidence. to challenge patients and healthcare on the extremity. A trial of a double layer of Tubigrip™ professionals alike. Below-knee styles are indicated if the (Mölnlycke Health Care) may be useful to majority of the oedema is in the lower begin this process. Conclusion half of the leg. The garment needs to finish Difficulties donning and doffing Compression garments are important clear of the knee crease to reduce the risk garments are a challenge. An array of and effective tools in the management of of rolling at the proximal end. assistive devices is available (Figure 4). lymphoedema. They can facilitate self- Thigh-length or pantyhose styles are These are available through medical supply sufficiency and self-care. Compression indicated if the majority of the oedema is companies. Velcro-style wrap garments needs to be managed carefully as part of a in the thigh. Layering may be beneficial are a recent addition. These are easier for wider management plan, however, in order

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to be safe and effective. It can work in a 03.04.2017) This article first appeared in our sister publication Wounds complimentary manner with a number of Most G, Picerni P, Partsch H (2012) Compression stockings International. Citation: Scheer (2017) Clinical innovation: with moderate pressure are able to reduce chronic leg treatment modalities for the management oedema. Phlebology 27(6): 289–96 compression garments for managing lymphoedema. of lymphoedema. New technologies, Nikolaidis, P Karlsson K, Nikolaidis P (2015) Evidence- Wounds International 8(2): 34–8 based or traditional treatment of cancer-related fabrics and garment designs means the lymphedema. Lymphology 48(1): 24–7 patient and prescriber need to remain up Queensland Health (2014) Provision of Compression to date with what is available and what Garments. Available at: www.health.qld.gov.au/ahwac/ works most effectively for the individual. html/compression.asp (accessed 03.04.2017) Ridner, Sheila H (2013) A pilot randomized trial evaluating Australia has its own unique challenges low-level laser therapy as an alternative treatment to in managing lymphoedema, but many manual lymphatic drainage for breast cancer-related lymphedema. Oncol Nurs Forum 40(4): 383–93 challenges are shared internationally. Scheer R, Sanderson P, Phillips J (2006) Towards Best Practice in the Provision of Garments. Presented at: References Australasian Lymphology Association Conference, Australian Bureau of Statistics (2016) Population Clock. Melbourne, Australia Available at: www.abs.gov.au/ausstats/[email protected]/ Shih YT, Xu Y, Cormier JN et al (2009) Incidence, Web+Pages/Population+Clock?opendocument treatment costs, and complications of lymphedema after (accessed 03.04.2017) breast cancer among women of working age: A 2-year Lymphoedema Framework (2006) Best Practice for the follow-up study. J Clin Oncol 27(12): 2007–14 Management of Lymphoedema. International Consensus. Todd M (2015) Selecting compression hosiery. Br J Nurs MEP Ltd, London 24(4): 210–2 Mercy Health (2015) Lymphoedema Compression Garment Wounds International (2013) Principles of Compression in Program. Available at: www.mercyhealth.com.au/ Venous Disease: a Practitioner’s Guide to Treatment and hcmhs/services/l-n/Pages/Lymphoedema%20 Prevention of Venous Leg Ulcers. Wounds International, Compression%20Garment%20Program.aspx (accessed London

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