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Best Practice Statement Compression hosiery: A patient-centric approach 2021

THIRD EDITION

Understanding medical compression hosiery construction Individualised hosiery selection Shared decision-making

BEST PRACTICE STATEMENT: EXPERT WORKING GROUP: COMPRESSION HOSIERY: Jacqui Fletcher OBE (Chair), Independent Nurse Consultant A PATIENT-CENTRIC APPROACH Leanne Atkin, Vascular Nurse Consultant, Mid Yorkshire (3RD EDITION) NHS Trust; Lecturer, University of Huddersfield Louise Bolton, Tissue Viability Lead Nurse, Anglian PUBLISHED BY: Community Enterprise CIC Wounds UK A division of Alan Elstone, Vascular Nurse Specialist, Derriford Hospital, Omniamed Communications Plymouth/Advanced Clinical Practitioner, University Hospitals 108 Cannon Street, Plymouth NHS Trust London EC4N 6EU, UK Tel: +44 (0)20 3735 8244 Patryk Gawrysiak, Specialist Physiotherapist in www.wounds-uk.com Lymphoedema, St. George’s Hospital, London Caitriona O’Neill, Director of Clinical Services & Clinical Lead for Lymphoedema, Accelerate CIC

Georgina Ritchie, Deputy Director of Education, Accelerate © Wounds UK, June 2021 CIC

This document has been developed REVIEW PANEL: by Wounds UK and is supported by Philip Stather, Consultant Vascular Surgeon, Norfolk and an educational grant from Norwich University Hospitals, NHS Foundation Trust medi UK. Peter Vowden, Honorary Consultant Vascular Surgeon, Bradford Teaching Hospitals NHS Foundation Trust; Visiting Honorary Professor, Wound Healing Research, University of Bradford

Alison Hopkins MBE, Chief Executive, Accelerate CIC

The views expressed are those of the Document summary Expert Working Group and Review ■ Medical compression is an effective and powerful therapy. Panel and do not necessarily reflect those of medi UK. ■ Compression hosiery has evolved considerably over the last few years and is now a progressive therapy that exists How to cite this document: beyond Compression Class I and Class II British Standard Wounds UK (2021) Best Practice Statement: Compression hosiery: A hosiery. patient-centric approach (3rd edn). ■ It is important to be familiar with the National Wound Care Wounds UK, London. Available to download from: Strategy Programme (2020) guidelines and follow the www.wounds-uk.com recommendations in practice. ■ It is important to be familiar with the types of compression therapy used in clinical practice, the conditions that can be treated, and the garments available on local formulary. ■ It should be possible to find compression therapy for everyone with a thorough holistic assessment and taking into account individual patient preferences. ■ Effective communication and shared decision-making between the clinician and the patient and/or caregiver are key to identifying the ‘best’ hosiery for the patient and to ensuring concordance with care. Listen and understand their concerns, expectations and motivations with regard to their presenting condition(s). Avoid using terms the patient may not understand. Foreword

The third edition of the Best Practice The document is designed to be simple Statement on Compression Hosiery focuses and user-friendly, and to put the patient on improving the patient experience of at the centre of assessing for, selecting, medical compression hosiery for the lower prescribing and delivering care with medical leg, which include and , by compression hosiery. understanding the patient’s perspective and fostering a patient–practitioner partnership Jacqui Fletcher OBE, Chair for supported self-management. Progress since the It is often easy to label a patient ‘uncooperative’ Glossary (page 2) second edition or ‘non-concordant’ if the outcomes of (page 4) treatment are not as anticipated. However, it is unlikely that any patient is truly non- concordant, rather, they have not yet received the right treatment, education, support and follow-up for their individual needs. Clinicians Chapter 1: Principles of assessment (page 5) should employ a positive, confident, competent - Factors that influence medical compression and knowledgeable attitude when discussing hosiery selection medical compression therapy with patients, which may help to influence the patient to become interested and engaged with their Chapter 2: Medical compression hosiery treatment. construction explained (page 7) - The role stiffness plays in compression hosiery garments The COVID-19 pandemic has accelerated - Myths and truths surrounding round-knit initiatives towards greater patient and carer versus flat-knit hosiery supported self-management (NHS England and NHS Improvement, 2020). Consultations have increasingly been undertaken by Chapter 3: Patient considerations during medi- telephone and video call, and patients have cal compression hosiery selection (page 10) been able to text or send photos directly to - Clinical and patient-related factors that their clinician. Evidence shows that when impact on hosiery selection people are supported in self-management, they benefit from better health outcomes, improved experiences of care and fewer unplanned care admissions (NHS England Chapter 4: Encouraging shared and NHS Improvement, 2020). A growing decision-making (page 13) - Practical guidance on partnership working and number of people with wounds are willing concordance alongside the patient to participate in supported self-management if they are given the right support and tools (Adderley, 2020). Chapter 5: Measuring and sizing (page 15) An Expert Wound Group met online to - Myths and truths surrounding off-the-shelf discuss the advances in medical compression and made-to-measure hosiery hosiery since the second edition of the Best - FAQs on fitting medical compression hosiery Practice Statement: Compression Hosiery (Wounds UK, 2015) and to agree on Best Practice Statements to guide compression Chapter 6: Key elements of supported hosiery selection for patients. Best Practice self-management: Hosiery application, removal Statements are accompanied by Patient and care and skin care (page 17) Expectations to encourage shared decision- - Quick guide for good medical compression making and foster a supportive patient– hosiery fit practitioner partnership at every stage of care.

BEST PRACTICE STATEMENT: COMPRESSION HOSIERY 1 Glossary

Ankle–brachial­ pressure index (ABPI): A management of lower limb lymphoedema screening tool to determine the presence and and oedema. Hosiery can also be used extent of peripheral arterial disease (PAD). The to manage conditions associated with result of the ABPI rules out PAD, but it does CVI (NICE, 2012). Medical compression not confirm whether a patient will benefit from hosiery options vary in stiffness, levels of compression therapy – meaning that an ABPI compression delivered, fabric, colour, size, cannot diagnose venous insufficiency or the length, and whether they are closed or open- cause of oedema. toe. Medical compression hosiery is a single garment and can be selected off-the-shelf or Chronic venous insufficiency (CVI): A made-to-measure for the patient. condition whereby blood pools in the veins, straining the walls of the vein and making Compression hosiery kits: A type of it difficult for blood to return to the heart medical compression therapy most from the legs. It can be caused by venous commonly used for the management and hypertension or venous obstruction/occlusion, healing of venous leg ulceration. Kits consist such as a deep vein thrombosis. of two medical compression garments designed to be worn one on of the Compression: A treatment whereby the other. Hosiery kits are designed to be worn application of external pressure counteracts 24 hours a day but the outer layer can the loss of capillary fluid by squeezing fluid be removed at night, although this is not into the veins and lymph vessels. Compression essential. Hosiery kits are most commonly therapy improves venous return to the heart available in off-the-shelf sizes but can also be and initiates a variety of complex physiological made-to-measure. and biochemical effects involving the venous, arterial and lymphatic systems. The effects Compression standards: National of compression can be dramatic, reducing and international standards for medical oedema and pain while promoting healing of compression hosiery have been developed to ulcers caused by venous insufficiency (Harding ensure compression stockings and socks meet et al, 2015). certain technical parameters, such as testing methods, yarn specification and durability Compression bandages: A type of (Lymphoedema Framework, 2006). There are medical that is a variety of quality standards against which composed of either inelastic (short-stretch) compression hosiery can be categorised: elements, elastic (long-stretch) elements ■ British Standard Compression (Specifica- or a combination of both. Bandaging is tion 40; BS 661210): The British Standard for most often used to treat active venous compression hosiery has three classes that ulceration and should be worn 24 hours a indicate the level of compression provided by day. Bandaging can also be used for ongoing the garment. BS40 measures the compression maintenance, for those unable to tolerate delivered by the medical compression gar- hosiery or those with complex conditions ment at the ankle, knee and top of thigh and such as lymphoedema, especially when the has a 3-month guarantee (Partsch, 2003). legs are large and have skin folds. For these ■ German RAL (GZ 387/1) Standard: The Ger- patients, full-leg bandaging may be required man standard is measured at 5cm increments to control oedema and maintain the shape of up the garment to ensure graduation and has the leg (Anderson and Smith, 2004). a 6-month guarantee (Földi and Földi, 1983). ■ French Standard (ASQUAL) (AFNOR NF Compression classes: The pressure measured 30.102A): The French Standard is measured at at the ankle is used to classify medical the ankle (Levick, 2003). compression hosiery into compression classes (e.g. 1, 2, 3). The stiffness of the compression Compression wraps: A type of medical hosiery material affects the compression class. compression garment considered for the management of lymphoedema and other Compression hosiery: The most widely disorders of the circulatory system. Available used form of compression in the long-term in a variety of forms, these devices consist

2 BEST PRACTICE STATEMENT: COMPRESSION HOSIERY GLOSSARY

of fabric sheets made from one or more cellulitis, fluid leakage and ulceration (Bianchi components with limited extensibility. The et al, 2012; Harding et al, 2015). Chronic wraps are applied to affected limbs and oedema can be considered a surrogate marker held in place with hook and loop fastenings for lymphoedema. (Thomas, 2017). Static Stiffness Index (SSI): The difference Interface pressure: The pressure between between standing and resting pressure the skin and the compression garment. characterises the efficacy of a specific Measuring pressure at the interface during compression garment to narrow the venous both lying and standing indicates how the lumen and encourage venous return (Partsch compression garment reacts to muscular et al, 2016). The Dynamic Stiffness Index (DSI) activity. The interface pressure was is the change in the pressure between the previously described as the sub-bandage limb and garment (interface pressure) when pressure. a person activates their calf muscle through movement, such as walking or exercise. The Lymphoedema: The accumulation of DSI demonstrates the garment’s ability to resist fluid in the tissue spaces. It may present calf muscle expansion and to generate working as swelling of one or more limbs and may pressure increases. The higher the SSI and DSI, include the corresponding quadrant of the stiffer the garment. the trunk and other areas, e.g. head, neck, breast or genitalia. It arises from congenital Stiffness: A measure of flexibility and the malformation of the lymphatic system ability of the bandage or hosiery to oppose (primary lymphoedema), or damage to the muscle expansion during contraction lymphatic vessels and/or lymph nodes (Mosti, 2012). The yarn used and the technique (secondary lymphoedema) due to cancer employed to knit the fabric will impact the treatment, infection, inflammation, stiffness of the fabric. The less stiff the material, venous diseases, obesity, trauma and the lower the pressure peaks during exercise. injury (Lymphoedema Framework, 2006). Inelastic bandage and multi-layer bandage Lymphoedema is a progressive disease of systems generally have a higher SSI when four stages: latency stage (stage 0), mild stage compared to compression hosiery (Vowden et (stage 1), moderate stage (stage 2) and severe al, 2020). stage (stage 3) (International Society of Lymphoedema, 2016).

Oedema: Swelling caused by the accumulation of fluid in the extra-vascular tissue. Oedema usually affects the feet, ankles and legs, although it can occur anywhere in the body. The cause of oedema should be identified before beginning treatment. Bilateral oedema is indicative of systemic conditions such as cardiac failure, protein reduction and venous insufficiency, standing or sitting in the same position for too long, eating a large amount of salty foods, being overweight, being pregnant, malignancy or taking certain medicines. Unilateral oedema is more often due to local causes, such as deep vein thrombosis or cellulitis.

Chronic lower limb oedema is a persistent, abnormal swelling of the leg. Chronic oedema has an ongoing effect on the viability of the skin leading to complications, such as infection,

BEST PRACTICE STATEMENT: COMPRESSION HOSIERY 3 PROGRESS SINCE THE SECOND EDITION

Clinicians should stay Since 2015 and the second edition of the Increasing range of medical updated with evidence Best Practice Statement there have been compression hosiery and guidelines on the use the following areas of progress in medical Compression hosiery has evolved of medical compression compression therapy. considerably over the last few years and is therapy. Clinicians now a progressive therapy that goes beyond should be familiar with National Wound Care Strategy Class I and Class II British Standard hosiery. the different types of Programme guidance There is now a greater variety of medical compression systems In England, the National Wound Care compression hosiery available in terms of and know when and how Strategy Programme (NWCSP, 2020) style, which increases the expectations of to access and use them. has produced recommendations for the what can be achieved for patients. However, Failure to provide a patient with appropriate care immediate and necessary care of patients variations in styles can lead to inconsistency should be seen as a harm. who have one or more wounds below in the way medical compression garments the knee. The recommendations include are selected and prescribed (NICE, 2012). guidance on wound and skin cleansing, Patients may attend appointments having application of a simple low-adherent already looked at the options online, but Best Practice dressing and the use of mild graduated it is important to remember that not all Statement compression for leg wounds if there are medical compression hosiery are available no red flags to contraindicate compression on every Trust’s formulary. Therefore, (Box 1). clinicians should be familiar with the garments that they have available in order Medical compression Medical compression is a powerful, to select the most appropriate garment for is an active therapy and active therapy that is part of the toolkit the patient. will help to reduce your for the management of chronic oedema, symptoms. You should lymphoedema and venous insufficiency. NHS Long-Term Plan expect your clinician to be In the absence of red flags (Box 1), mild The NHS Long-Term Plan (2019) is a confident, competent and compression (around 20mmHg at the commitment to facilitating measurable enthusiastic about medical ankle) should be considered the first-line improvements in population health and compression. They should be familiar with different initial treatment for people who have one to reduce health inequalities. In wound types of compression or more wounds below the knee and not on care, the NWCSP (2020) recommends (e.g. compression hosiery, the foot (NWCSP, 2020). The patient should greater awareness of the importance stockings, bandages and receive a full holistic assessment if clinically of early intervention of compression wraps), so that they can required or if there is evidence of venous therapy or endovenous intervention. This offer treatments that and/or lymphatic disease, with a view to is to be achieved through greater public you. increasing the level of compression within awareness (e.g. public-facing campaigns 14 days. This is clear national guidance that such as Legs Matter https://legsmatter.org) Patient healthcare professionals should encourage and community, primary care, vascular, compression uptake among patients; failure tissue viability and lymphoedema services expectation to provide a patient with appropriate care promoting the same prevention and early may be seen as a harm. intervention messages.

Box 1. National Wound Care Strategy Programme (2020) guidance for people with leg and foot wounds

If red flags are present: People with leg and foot wounds should not be ■ Treat suspected infection in line with treated with compression if they have any of the following red flags: NICE (2020) antimicrobial guidelines ■ Immediately escalate to relevant • Acute infection of leg or foot (e.g. increasing clinical specialist unilateral redness, swelling, pain, pus, heat) ■ For people in the last few weeks of life, • Symptoms of sepsis seek input from their other clinicians • Acute or chronic limb-threatening ischaemia to agree an appropriate care plan. • Suspected acute deep vein thrombosis • Suspected skin cancer.

4 BEST PRACTICE STATEMENT: COMPRESSION HOSIERY CHAPTER 1: PRINCIPLES OF ASSESSMENT

Selecting the correct Medical compression hosiery is the most Holistic assessment medical compression widely used form of compression in the long- A detailed history should include past hosiery should be based term management for a number of condi- medical and surgical history, family history on a thorough assessment tions, including lower limb lymphoedema and history of limb or skin trauma. Current of the patient’s presenting and oedema, and conditions associated with medications (e.g. ACE inhibitors, inmmuno- symptoms and knowledge chronic venous insufficiency (CVI: NICE, suppressants, steroids), concurrent illnesses of how the products work. 2012). Venous disease can be categorised us- and the patient’s limb, circulation and skin ing the CEAP classification (Lurie et al, 2020; should also be assessed to identify the cause Best Practice Table 3, page 12) to differentiate between of venous insufficiency or chronic oedema mild (thread veins or telangiectasia) and and underlying disease process (Lymphoe- Statement severe (chronic skin changes/ skin discoloura- dema Framework, 2006). tion/ulceration). Untreated CVI can also lead to oedema formation. There are many causes The NWCSP (2020) offers guidance on the of chronic oedema, but they largely fall into key elements of assessment that will guide Assessment for medical four main categories: first-line intervention and provides red flags compression should ■ Lymphoedema (both primary and sec- for when compression therapy should not be include full assessment of your limb, other ondary) initiated (Box 1, page 4). ■ conditions, home life, Lipoedema ■ personal preferences, your Dependency oedema Vascular assessment willingness to be involved ■ Lymphovenous or phlebolymphoedema The ankle–brachial pressure index (ABPI) in care, and your ability to (Green and Mason, 2006). result along with the patient’s history and apply and remove medical other elements of the assessment process can compression hosiery. Many of the signs and symptoms of chronic be used to rule out the presence of significant oedema — including dermatitis, distortion peripheral arterial disease (PAD). There is a of limb shape, episodes of cellulitis, develop- common misconception that garment selec- Patient ment of hyperkeratosis, non-pitting when tion relies solely on the compression class or expectation pressure is applied and hyper-pigmentation mmHg and the result of the ABPI. of the skin — may be indicative of these potential venous or lymphatic conditions. Therefore, it may be difficult to differenti- ate between venous and lymphatic diseases, MYTH highlighting that a full, holistic assessment is required for patients with chronic oedema The ABPI result will indicate the (Wounds UK, 2015). compression class or level that the patient requires.. An accurate assessment of the patient, their preferences, the severity of the disease pro- gression, and any complications or comorbid TRUTH conditions will inform the treatment pathway and compression garment selection. If gar- Compression up to 20mmHg can be ments are to be used safely, all patients need applied in the absence of red flags to be able to report concerns they have with without any form of arterial assessment their medical compression hosiery; this is (NWCSP, 2020). An ABPI assessment is recommended before commencing especially important where there is neuropa- compression therapy greater than thy or cognitive impairment. The provision 20mmHg. The role of the ABPI of compression hosiery relies on the patient’s assessment is to screen patients to rule protective sensation and their ability to rec- P out PAD. Compression selection should ognise problems; where this may be an issue, be based on the clinical assessment, more regular review of the patient may be patient expectations and aim of required. compression therapy in combination with the ABPI result.

BEST PRACTICE STATEMENT: COMPRESSION HOSIERY 5 1. PRINCIPLES OF ASSESSMENT

Instead, the results of the ABPI may influence The BLS (2019) Position Document offers compression selection, and, it is important to further guidance on how to assess limbs in the remember that, in the presence of significant presence of oedema. PAD, compression therapy can be dangerous and should only be used at the recommenda- Treatment plan tion of a vascular specialist. For more infor- Results from the mediven® observational study mation on the role of ABPI, see Best Practice found that patients’ individual factors were Statement: Ankle–brachial pressure index rarely taken into account when prescribing (ABPI) in practice (Wounds UK, 2019a). medical compression garments (Schwahn- Schreiber et al, 2016). Just as medication If an ABPI cannot be obtained, for instance, dosage is prescribed according to the needs the patient is unable to lie flat, or has oedema- and characteristics of the individual, selection tous legs, pain, fragile skin or calcified vessels, of compression therapy should be based on the arterial supply needs to be assessed in careful assessment of the patient’s individual other ways, for example toe pressure, pulse needs and condition identified in the holistic auscultation and pulse palpation. If it is not assessment, taking into consideration patient possible to obtain an ABPI initially due to choice (Figure 1). oedema, then it may be helpful to apply compression therapy at 20mmHg to manage the oedema and attempt to obtain an ABPI the following week.

Arterial assessment e.g. ABPI, toe pressure, pulse palpation

Holistic Patient assessment choice identifies level of Medical compression e.g. style, colour, compression needed hosiery selection ability and willingness to treat underlying to self-manage cause/symptoms

Individual patient factors identified during holistic assessment, e.g. BMI, mobility, limb shape

Figure 1. Factors that influence medical compression hosiery selection.

6 BEST PRACTICE STATEMENT: COMPRESSION HOSIERY CHAPTER 2: MEDICAL COMPRESSION HOSIERY CONSTRUCTION

Medical compression hosiery must be se- Elasticity and stiffness – Practitioners should lected based on the outcomes of the holistic How compression works understand the range assessment, patient preferences and the goals Inelastic compression systems generally of medical compression of treatment. Product selection should also have a higher Static Stiffness Index (SSI) hosiery garments available and understand how take into account limb size and shape, skin compared to elastic compression systems. the construction of the condition, allergies and sensitivities, patient Stiffer compression systems have higher garment affects clinical considerations (e.g. dexterity, psychosocial working pressure peaks and can be more efficacy. issues) and the garment itself. comfortable than more elastic garments with a lower SSI as they support the leg Construction of compression hosiery and provide ‘strong wall stability’. Best Practice The type of yarns and techniques Statement used to manufacture medical compression Conversely, the leg muscles contract and hosiery affects the stiffness or elasticity of the change shape during walking and exer- garment. The material used to make compres- cising, so compression garments have to sion garments is produced by knitting two Using language you provide some elasticity to allow this move- understand, the clinician types of yarn together: ment while still supporting calf action and ■ should be able to explain to Inlay yarn – produces the compression counteracting the gravitational effect of ■ you the different medical Body yarn – delivers the thickness and standing. compression hosiery stiffness of the knitted fabric (Clark and garments available and help Krimmel, 2006). to find the best garment to MYTH suit your individual needs. The arrangement of the inlay and body yarn will produce either flat-knit or round-knit Stiffer medical compression hosiery is Patient fabric, which impacts on the material’s prop- sometimes perceived as uncomfortable. expectation erties and indications for use (Table 1, page 8). Flat-knit fabric tends to be relatively thick, stiff and inelastic, which lets it lie across skin TRUTH folds without cutting into the skin. Flat-knit is usually used for ‘made-to measure’ garments Stiff or inelastic medical compression because it can be more readily adapted to hosiery provides higher working pressure limb shape distortion. ‘Off-the-shelf’ medical peaks while the patient is walking or exercising but is comfortable at rest. compression hosiery is available in standard sizes and tends to be manufactured from round-knit fabric. Compression standards Medical compression hosiery is a medical device, so it is measured against set cri- teria to describe the support or compres- MYTH sion applied to the lower leg. Standards provide confidence about the quality and Flat-knit medical compression hosiery should life span of a product. It is important to be used as a ‘last resort’ for patients as they know how long a product is able to give are difficult to measure patients for and mistakes are expensive and wasteful. therapeutic levels of compression to avoid putting patients at risk of sub-standard care (Lymphoedema Framework, 2006). For medical compression hosiery, there TRUTHTRUTH are three internationally recognised qual- ity compression standards – British Stan- Flat-knit medical compression hosiery dard, German RAL Standard and French often requires a few more measurements, Standard (Table 2, page 9). but, for patients with chronic oedema/ lymphoedema, it is the optimal therapy and should be considered once the initial There is no independent quality European reducible oedema has been decreased. standard, but the German RAL Standard is widely accepted as the basic requirement

BEST PRACTICE STATEMENT: COMPRESSION HOSIERY 7 2. MEDICAL COMPRESSION HOSIERY

Table 1. Features of round-knit and flat-knit medical compression hosiery Feature Round-knit compression hosiery Flat-knit compression hosiery

Seam Seamless With seam Manufacturing

Knit Knitted on a round cylinder Knitted in flat rows Stitches per row Constant Variable Shape Shaped by variable mesh size and pretension of the inlaid Shaped by variable number of stitches with the elastic thread elastic thread laid in Stretch High Low Thread structure

Elastic thread Not covered Covered Working pressure Low High Effect Effect on veins to improve venous return Primary effect is to increase tissue pressure Secondary effect is on the veins to improve venous return Measurement When measuring the patient’s limb, measure the surface When measuring the patient’s limb, there is a degree of circumferences interpretation required as the garment is designed to sculpt the limb rather than necessarily match the size and shape presented Uses Generally used for off-the-shelf hosiery, although it can be used Commonly used for made-to-measure hosiery for made-to-measure hosiery Indications Typically for patients who have venous insufficiency or mild Typically for patients who have chronic oedema/lymphoedema lymphoedema due to the action on the limb, and its ability to be knitted to fit any limb shape Most suitable where there is no or minimal limb distortion due to oedema (Anderson and Smith, 2014) If round-knit is causing problems for the patient, consider flat- knit, which can be more comfortable and easier to apply

Images used with permission of medi UK©.

8 BEST PRACTICE STATEMENT: COMPRESSION HOSIERY 2. MEDICAL COMPRESSION HOSIERY

for certifying medical compression stock- when selecting medical compression ings (BSI Standards Publication, 2018). hosiery, more emphasis should be given to Clinicians should check that the medical the compression dosage (mmHg) required compression hosiery they are using has for the patient’s individual needs rather a quality standard as this will guarantee than the compression class of the garment. the offers the correct ‘dosage’ of mmHg and that it delivers consistent graduation of pressure levels, i.e. higher at the ankle, and reducing throughout the MYTH length of the stocking. When choosing a medical compression Compression class garment, the compression class and The elasticity and stiffness of the textile compression dosage (mmHg) are the most has a great impact on the haemodynamic important aspect to consider. efficacy of a garment (Bjork and Ehmann, 2019). The stiffness of the compression ho- siery material affects the compression lev- TRUTH els exerted by different types and classes of hosiery. The compression measured at the In most clinical situations, it is important ankle is used to classify the hosiery into to consider a holistic approach (e.g. BMI, compression classes; however, the pres- limb shape, disease severity, patient sure range used to define each class varies preference and ability) before deciding between the different standards, and what medical compression hosiery different techniques are used to measure garment will provide the right compression dosage (mmHg) for the patient. the levels of compression (Lymphoedema Framework, 2006) (Table 2). As a result,

Table 2. Classes and standards of medical compression hosiery Compression standards Compression class British standard 40 French Standard German Standard (BS 661210) 3-month guarantee (AFNOR NF 30.102A) (RAL GZ 387/1) 6-month guarantee (Partsch, 2003) (Levick, 2003) (Földi and Földi, 1983) Class 1 mild 14–17mmHg 10–15mmHg 18–21mmHg compression Class 2 moderate 18–24mmHg 15–20mmHg 23–32mmHg compression Class 3 strong 25–35mmHg 20–36mmHg 34–46mmHg compression

Class 4 extra strong ­Not available >36mmHg >49mmHg compression

BEST PRACTICE STATEMENT: COMPRESSION HOSIERY 9 CHAPTER 3: PATIENT CONSIDERATIONS DURING MEDICAL COMPRESSION HOSIERY SELECTION

The patient’s clinical Different types of hosiery should be used Medical compression hosiery is available presentation and at different stages of disease progression, as open-toe or closed-toe garments. In the preferences should be depending on the conditions and symptoms close-toe option, the toe compartment of the assessed during hosiery present, and whether or not oedema is pres- hosiery does not provide sufficient compres- selection (e.g. presence ent. Compression garments are not a ‘one- sion at the tip, but it does provide contain- of oedema, venous size-fits-all’ prescription. ment. It is important to protect the toes; insufficiency and their this can be achieved through the use of toe body size, limb shape, Role of compression in oedema gloves or , depending on the extent of the size and shape of foot and Any form of oedema (i.e. oedema, chronic oedema, patient choice and ability to apply manual dexterity). oedema or lymphoedema) is a cause of con- (Elwell, 2014). Toe gloves can be used with cern, and patients with oedema should seek open-toe or closed-toe hosiery. Best Practice help as soon as possible and not wait until Statement issues have developed. Patients with signs and Open-toe hosiery is frequently considered symptoms of lymphatic insufficiency should easier to apply due to the fact they are often be prescribed appropriate hosiery as early as supplied with a `silk-like ` device to aid possible to manage the underlying condition application. A patient may require open-toe Your clinician should and prevent disease progression (Anderson hosiery because: identify the medical and Smith, 2014). Without appropriate treat- ■ The patient has arthritic or clawed toes compression hosiery that ment to reduce the oedema, the affected tis- ■ The patient has a fungal infection is best for your clinical sues become progressively hard, fibrosed and ■ The patient prefers to wear a over individual needs. Your non-pitting, and the oedema fails to reduce the compression hosiery compression garment on elevation. Patients with oedema will have ■ The patient has a long foot size compared should be comfortable to an altered leg shape, which may include large with calf size (hosiery with longer foot- wear. If it is uncomfortable, skin folds especially around the ankle and size options are available, if necessary) an alternative garment ■ should be chosen. knee making it difficult to ascertain where the The patient requires regular podiatry/ knee joint is. This can be exacerbated if the chiropody appointments Patient individual is overweight. ■ There is no oedema present in the toes, and the patient prefers open-toe hosiery expectation In patients with chronic oedema, the key (NICE, 2012). function of hosiery is ongoing maintenance (Wounds UK, 2015). Compression com- Role of medical hosiery for patients with bined with exercise increases lymph flow and venous insufficiency venous return, thus reducing the volume of The therapeutic aim of compression for venous oedema. In addition, compression increases insufficiency is to provide the highest level of the blood flow into the microcirculation, compression possible that is tolerated by the which may improve wound healing and help patient. National guidelines (NWCSP, 2020) soften thickened or ‘woody’ tissues (Elwell, suggest the use of 2-layer compression kits that 2014). A made-to-measure medical compres- offer a minimum of 40mmHg as first-line, cost- sion hosiery garment may be more practical effective treatment of venous leg ulceration. for people with oedema as it can be measured to the patient’s limb size and shape. Compression hosiery is most commonly used by patients with venous insufficiency Toe oedema for either primary prevention or post-ulcer Toe oedema can be a natural occurrence in healing to control oedema and reduce venous chronic oedema, but it can also be induced by hypertension. incorrectly applied compression bandaging that leaves the toes, and often the forefoot, People with healed venous leg ulcers and no vulnerable without compression (Elwell, symptoms of arterial insufficiency should 2014). Oedema management requires ongo- be prescribed medical compression hosiery ing maintenance, so if toe oedema is initially and reviewed 6-monthly for replacement resolved with bandaging, the patient will need compression garments and ongoing advice to be monitored and compression continued about prevention of recurrence (SIGN, 2010; with compression hosiery. NWCSP, 2020).

10 BEST PRACTICE STATEMENT: COMPRESSION HOSIERY 3. CLINICAL CONSIDERATIONS

Patient-related factors account when deciding which medical Ultimately, the hosiery selected should be compression hosiery to use. the patient’s choice. The practitioner’s job is to explain the available options and direct Table 3 (page 12) offers suggestions for the patient towards the clinically optimal medical compression hosiery and additional choice. One of the most important factors treatment to manage the symptoms of venous with regard to hosiery selection, partnership- insufficiency and oedema/lymphoedema. working and concordance is understanding There are tools available that can help guide the patient’s motivations and what is hosiery prescribing, for example, The Hosiery important to the patient in their life. Hunter® tool focuses on the patient’s disease progression and clinical symptoms, BMI and The practitioner should listen to the patient limb shape (Wounds UK, 2019b). and identify and understand the issues that may result in non-concordance (Wounds UK, 2015). Figure 2 summarises the patient- specific factors that should be taken into

Patient preference e.g. style, appearance, colour.

Obesity Consider systems Skin condition or stiffer flat-knit hosiery See tips for skin care that has a higher SSI and under compression ‘strong wall stability’ hosiery to hold the tissue. (page 19). Also consider hosiery application aids (page 17).

Low dexterity or Consider limb shape mobility Bandaging, wrap Consider supplying systems or a stiffer flat- patients with an aid knit compression hosiery to application to reshape distorted limb (page 17). shape and skin folds.

Patient motivation Ask the patient what is important to them and what impact treatment has on their daily life.

Figure 2. Patient factors to consider during garment selection.

BEST PRACTICE STATEMENT: COMPRESSION HOSIERY 11 3. PATIENT CONSIDERATIONS

Table 3. Suggestions for medical compression hosiery and additional treatment for venous insufficiency and oedema Clinical indications Medical compression hosiery suggestion Additional treatment suggestions C0 No visible or palpable signs of No treatment required No treatment required venous disease C1 Telangiectasias or reticular veins C2 Varicose veins ■ Round-knit, off-the-shelf, RAL Standard ■ Daily skin care and emollient regimen to main- C2r Recurrent varicose veins compression tain skin integrity C3 Oedema ■ CCl 1 (18–21mmHg) or CCl 2 (23–25mmHg) ■ Simple ankle/calf exercises to enhance the calf may be most appropriate muscle pump function ■ For patients who do not fit in standard sizes, ■ Increased activity/mobility, such as short walks made-to-measure round-knit RAL Standard or water exercises (e.g. walking in shoulder- options should be considered. If there is high water, aqua-aerobics or aqua-cycling, but significant shape distortion, flat-knit, made- not swimming). A GP gym referral scheme to-measure hosiery in CCl 1–3 should be may be available in some areas considered. ■ Limb elevation on resting ■ C4 Changes in skin and subcutaneous ■ Round-knit, off-the-shelf, RAL Standard Weight loss/maintenance (referral to dietitian tissue secondary to CVD compression or bariatric services) ■ C4a Pigmentation or eczema ■ CCl 2 (23–25mmHg) may be most appropriate If oedema is venous related and is persistent or C4b Lipodermatosclerosis or atrophie ■ For patients not fitting in to standard sizes, worsening, patients should be seen by a vascu- blanche round-knit, made-to-measure, RAL Standard lar specialist to explore venous intervention to C4c Corona phlebectatica hosiery should be considered. aid symptoms (NICE, 2021).

Venous insufficiency:Venous CEAP classification (Lurie et al, 2020) C5 Healed ulcer C6 Active venous ulcer ■ 2-layer compression hosiery kit or compression C6r Recurrent active venous ulcer bandaging providing a combined 40mmHg should be used.

Chronic oedema/lymphoedema ■ Round-knit, off-the-shelf, RAL Standard ■ Daily skin care and emollient regimen to main- stage 0–2 (latency, mild or moderate) compression may be suitable in early stages tain skin integrity ■ Flat-knit, made-to-measure, RAL Standard ■ Simple ankle/calf exercises hosiery should be considered in most cases ■ Avoid sitting with leg dependant/sleeping in ■ CCl 1–4 may be most appropriate according the chair at night-time; this may undermine all to the holistic assessment of the individual and compression treatment/management their circumstances. ■ Increasing activity/mobility, such as short walks or water exercises (e.g. walking in shoulder-high water, aqua-aerobics or aqua cycling, but not swimming). A GP gym referral scheme may be available in some areas ■ Limb elevation on resting ■ Consider simple/manual lymphatic drainage.

Chronic oedema/lymphoedema ■ Flat-knit, made-to-measure, RAL Standard ■ As above for chronic oedema/lymphoedema stage 3 compression hosiery with a high SSI is often stage 0–2 the most suitable ■ Weight loss/maintenance (referral to dieti- ■ CCl 3 (35–45mmHg)­ or CCl 4 (>49mmHg) tian or bariatric services). may be most appropriate; however, CCl 2 (23–35mmHg) may be considered according Oedema classification (International Society of Lymphology, 2016) OedemaLymphology, classificationSociety (International of to the holistic assessment of the individual and their circumstances.

CCl: Compression class, CVD: Cardiovascular disease.

12 BEST PRACTICE STATEMENT: COMPRESSION HOSIERY CHAPTER 4: ENCOURAGING SHARED DECISION- MAKING

Patient adherence to compression therapy The focus of compression treatment is to The clinician should is often poor, but it is unhelpful to label slow disease progression, but it can be dif- be confident in their patients as intentionally non-adherent ficult for the patient to imagine what will own knowledge of (Green and Jester, 2019). Rather than happen if they do not wear compression. medical compression to dismissing the patient as non-adherent to A way of promoting concordance with confidently explain the impact of compression treatment, instead listen to the patient’s compression therapy is to ask the patient hosiery. During concerns and motivations with regard to to consider the future with regard to their consultations, explore the the presenting condition. To help to facili- lower limbs and to discuss the possible patient’s individual ideas, tate shared decision-making, use language consequences of not wearing compres- concerns and expectations that is appropriate for the patient and cre- sion therapy, i.e. What might occur if they of compression therapy. ate an open, accepting environment that choose not to wear it? What could life be allows the patient to share their own story. like in a few years’ time?

Best Practice It is acceptable to discuss compromise, as During appointments, explore with the Statement this may keep the patient engaged and can patient other avenues that will aid treat- help ease patients into accepting long- ment and make compression more toler- term treatments, such as medical com- able, such as skin care, elevation, activity, pression hosiery. Patients also need to be weight loss, access to support groups. Ask You should expect to be aware that their choice cannot always be questions that might not be directly relat- involved in making joint decisions about your care, fully accommodated, and that there may ed to compression therapy itself, but might feel able to voice your have to be some balance between clinical help to identify areas where the patient concerns and be reassured need and patient preference. Treatment could be supported. Box 2 includes areas that changes can be made can be modified to use a lower compres- of discussion for clinician and patient to to your care if required. sion if high compression is not tolerated help inform compression selection. Your clinician may ask at first, but discussions should include whether you have family/ the fact that as tolerance builds over time, ‘Best’ garment for the patient carers who would like to compression levels may also be increased. The ‘best’ garment for the patient is the take part in the care plan if Practitioners and patients alike should garment that they will use and wear cor- you need extra support. understand that compression is an on- rectly. To identify the best garment for the going treatment that needs to be worn patient: Patient long-term, just as long-term medication 1. Listen and explore: Explore the pa- expectation regimens should be adhered to. tient’s understanding, concerns and hopes related to medical compression hosiery (Box 2). 2. Assess: Assess the limb and patient to MYTH determine the most appropriate medi- cal compression hosiery clinically (see Wearing compression is always for life. Chapter 2). 3. Consider patient ability: Consider the patient’s ability to apply compression ho- TRUTH siery, for example their manual dexterity and their body size and shape. Some conditions such as lymphoedema 4. Check fit: Check how the medical com- require compression therapy for life, others, pression hosiery fits on the leg(s). such as varicose veins, may be surgically treated and may not require life-long 5. Patient preference: Ask the patient if therapy. For patients with chronic oedema they are happy with the appearance and and venous insufficiency where intervention fit of the medical compression hosiery. is not suitable, medical compression therapy is a life-long therapy.

BEST PRACTICE STATEMENT: COMPRESSION HOSIERY 13 4. SHARED DECISION-MAKING

Box 2. Questions to ask the patient during medical compression hosiery selection: gathering information and encouraging adherence

■ What do you understand about the condition in your leg(s)? ■ Have you used medical compression garments before? ■ If yes, how did they affect your day-to-day lifestyle? ■ What are your priorities for treatment? ■ Do you feel confident in applying and removing your hosiery? ■ Is there someone who can help you apply/remove your medical compression garments? ■ Are you happy with the medical compression hosiery’s colour? Pattern? Texture? Softness? (This is especially important to ask as summer approaches, so patients have medical compression they are comfortable with when wearing lighter/shorter clothing). ■ Would you prefer open- or closed-toe medical compression hosiery? ■ Do you have at least two pairs of medical compression hosiery? (Patients must wash and wear pairs alternately, and not keep one pair ‘in good shape’ for later).

Supporting patients at home MYTH To successfully support your patient to care at home, they need to have understanding of: ■ If the patient refuses to wear medical The reasons why hosiery has been pre- compression hosiery, there is nothing more scribed that can be done for the patient. ■ A well-fitting garment, skin care and how to apply and remove the garment ■ The expectations of care TRUTH ■ When they should contact the clinician and the ‘red flags’ If the patient refuses to wear medical ■ The emergency contact details of who to compression hosiery, listen to the patient’s contact if issues arise concerns and why they feel they cannot ■ When and how to re-order hosiery wear compression hosiery. Consider with the patient whether the expectations of care need to be modified. The expectations of Patients may also benefit from keeping a self- care should be agreed between the clinician care journal and being provided with where to and patient before treatment begins and access online patient resources (e.g. Legs Mat- revisited during treatment. ter campaign: www.legsmatter.org/help-infor- mation/resources) or advice leaflets designed for patients (e.g. www.lymphoedema.org). MYTH

Wearing medical compression hosiery is uncomfortable. TRUTHTRUTH

Patients with venous and lymphatic disorders should always feel more comfortable when wearing medical compression hosiery than when they are not.

14 BEST PRACTICE STATEMENT: COMPRESSION HOSIERY CHAPTER 5: MEASURING AND SIZING

Medical compression hosiery is only effective pressure to control their limb on an ongoing Limbs should be if the patient’s limbs are measured accurately basis. After measurement, it is important to measured and medical and the garment is applied correctly. Medical continue with compression bandaging until compression hosiery compression measured and prescribed inac- the patient’s compression hosiery garment prescribed according curately can lead to tissue trauma/pressure is available. Box 3 includes tips for hosiery to the manufacturer’s damage particularly if the fabric rolls during measurement. own measuring guide, as sizes vary according to wear or is too tight and digs into the skin manufacturer. There are (Robertson et al, 2014). These experiences If a patient does not fit the measurements on tools available to support may stop the patients wanting – or being able the manufacturer’s sizing chart for standard, clinicians to measure – to continue with treatment. off-the-shelf sizes, ‘made-to-measure’ medical and identify the correct compression hosiery should be prescribed. compression garment for Limbs should be measured and hosiery pre- Made-to-measure can be considered first line the patient. scribed according to each manufacturer’s own for chronic oedema and larger limbs with a measuring guide, as sizes vary according to shape, i.e smaller at the ankle, in- manufacturer. Every effort should be made to creasing in size up the leg. Where skins folds Best Practice reduce oedema before hosiery is measured. In are present compression bandaging will be re- Statement some cases, bandaging may be required dur- quired first to achieve reduction and reshap- ing the intensive management phase to help ing. If fitting is not accurate, hosiery will fail reshape the limb, reduce limb volume and/ to prevent oedema, maximise ulcer healing or or treat the ulcer. Once oedema has reduced, prevent recurrence, and will increase the risk patients can be measured for medical com- of skin damage complications (Wounds UK, You should expect your pression hosiery that will deliver sufficient 2015). clinician to measure both of your legs so that you can be prescribed appropriately Box 3. Tips for hosiery measurement (Wounds UK, 2015) sized medical compression hosiery. ■ Use the correct measuring guide for the brand of medical compression hosiery to be pre- scribed, as each manufacturer will vary Patient ■ Take measurements as early in the morning as possible, when oedema is at a minimum expectation (see below for common measurement points for A] off-the-shelf; and B] made-to-measure compression hosiery)

A. B.

Images used with permission of medi UK©.

■ Take measurements directly against the skin to ensure accuracy (use a skin marker to ensure accuracy and reproducability) ■ Take measurements for both leg, as they may differ in size ■ Take measurements when the patient is sitting down, with feet flat on the floor ■ If the patient has skin folds due to oedema or the limb is particularly misshapen, a specialist flat-knit garment may be required. This will require specialist assessment. ■ Ask the patient to wear their medical compression hosiery to the next appointment so that the fit can be re-evaluated.

BEST PRACTICE STATEMENT: COMPRESSION HOSIERY 15 5. MEASUREMENT AND SIZING

The practitioner should prescribe a minimum colour and options on prescription, which of two, but preferably three pairs of medi- may support concordance. Patients may be cal compression hosiery (one to wash, one given details of websites where they can re- air drying and one to wear) every 6 months search the hosiery products further online. (3 months for British Standard compres- sion hosiery), to ensure the effectiveness of compression. This is regardless of the type of compression or class. Prescriptions should MYTH be clearly and thoroughly specified to ensure accurate dispensing. The patient only ever needs two pairs of medical compression hosiery. When a new prescription is required, the pa- tient must be re-measured. If the patient has a current medical compression prescription, TRUTHTRUTH it should be continued until the new prescrip- It would be beneficial to the patient if tion is ready. If the weight of the patient re- clinicians prescribed a minimum of two duces or increases, this is likely to change the pairs of medical compression hosiery every size of the limb. Old, worn hosiery should be 6 months (3 months for British Standard). handed back to the clinician when the patient Some patients may be able to purchase more receives a new prescription to prevent the pairs privately if they are given the full details patient wearing old ‘comfy’ medical hosiery. of the garment. Some hosiery manufacturers a wide range of

Fitting FAQs

The patient has previously found compression uncomfortable and placement are correct, it may be beneficial to suggest and doesn’t want to try again – what do I do? using a garment with a different style or a stiffer fabric. If the If the patient did not tolerate compression in the past, it does hosiery are thigh-length garments and the hosiery fit has not mean that they will not be able to tolerate compression been checked, consider using an adhesive designed to adhere ever again. If the hosiery is not comfortable, it is not the right compression garments to the limb. choice for this patient right now. Talk to the patient again and listen to their concerns. How will I know that the compression garment is working? Compression therapy will help with limb volume reduction What if the hosiery digs in at the top around the knee? and leg comfort. If the leg was initially swollen and the medi- Check that the garment is not overstretched and that place- cal compression hosiery starts to loosen and fall down after ment is correct (the top band should sit two fingers’ width a few weeks, this could be a positive sign that treatment is from the crease of the knee). If the size and the placement are working. You might have to order a smaller-sized stocking correct, it may be beneficial to change the fabric. Contact your initially, depending on the condition you are treating and until local TVN/lymphoedema specialist if unsure. the limb is stable. The patient should know who to contact if the garment is getting loose quickly, and that this is not a sign What if the compression hosiery is too tight? that the compression therapy has worked and is no longer Ensure patients understand that a larger garment size will not required. make the garment feel less tight, and that this will reduce the effectiveness of the treatment. Less elastic garments may be What if the garment starts to fall down? useful if this feeling persists. Garments that continue to fall down cannot provide thera- peutic compression. If the garment fits and the fabric is the What if the top of the compression hosiery is rolling? correct type for the condition being treated, the use of a body Check that the garment is the correct size/measurement glue, or addition of a top band, may help to keep the garment and ensure placement is correct (with the top band sitting in place. two fingers’ width from the crease of the knee). If the size

16 BEST PRACTICE STATEMENT: COMPRESSION HOSIERY CHAPTER 6: KEY ELEMENTS TO SUPPORTED SELF- MANAGEMENT: HOSIERY APPLICATION, REMOVAL AND CARE, AND SKIN CARE

Hosiery application (donning) and sion stocking aid is usually made from a The practitioner who removal (doffing) slippery fabric, which is designed to make measured, selected and Even if the patient is experienced with it easier to compression hosiery over prescribed the medical compression hosiery, they should not the foot and leg. Patients will still need compression hosiery independently apply compression hosiery to be able to bend to reach their feet with should guide the patient through first application, for the first time or if the prescription has fabric aids. Rigid aids typically provide a and discuss how to apply changed. The practitioner should demon- frame that lets the patient step into hosiery and remove the hosiery, strate donning and doffing, then help the or pull up garments without bending to how to manage skin patient practise until they are competent at reach the floor (Dilks and Green, 2005). care under compression applying and taking off compression hosiery There are many different aids available, and how to take care of on their own. Showing how to apply and which should be chosen according to each compression hosiery. remove the hosiery and what constitutes a patient’s physical needs (Table 4, page 19). If this is not possible, good fit when a carer is present is beneficial another qualified, skilled (Box 4). Other aid options include non- mats, practitioner should guide roll-on adhesives and roll-on membranes. the patient. Box 4. Quick guide for good medical Wearing rubber gloves with soft interior compression hosiery fit linings can aid grip during application Best Practice ■ Hosiery should fit well and not feel loose and removal of all types of compression Statement ■ Hosiery should not be twisted, rolled or stockings. folded down ■ Hosiery should sit two fingers’ width below the knee crease, or four fingers’ width MYTH below the gluteal fold in thigh-length gar- The clinician who Hosiery application and removal aids are not measured and prescribed ments ■ available on the NHS. your medical compression The fabric should be evenly distributed hosiery should show you over the length of the garment how to apply (don) and ■ Hosiery should not pinch the skin or cause remove (doff) the hosiery, pain and provide you with ■ If numbness or pain occurs while wear- TRUTH advice on how to care ing medical compression, it should be Clinicians who prescribe compression for your limb, skin and removed and reported to the clinician who hosiery should ensure that they are familiar garments. If you do not prescribed the compression hosiery understand any part of with the aids that are available on FP10 ■ Hosiery should not cause shortness of what has been said, you locally and advise patients accordingly. breath. should ask for further explanation. Patient It is important to explain that compression hosiery application is a new skill, which Application & removal FAQs expectation may require patience and practice in the early phase of treatment. Patients should Can the patient wear compression while ensure they set aside time in their daily they sleep at night? routine and their environment is suit- It is preferable that the patient wears medi- able to apply/don and remove/doff their cal compression hosiery throughout the day hosiery. Instructions to apply thigh-length and removes them at night, allowing for the hosiery without a fabric or rigid aid are shown in Figure 3, page 18. skin to be routinely checked for compression damage and to be moisturised. However, If a patient finds it difficult to don their if the patient sleeps in a chair, they should hosiery, a hosiery application aid can help. wear medical hosiery throughout the night Application and removal aids are typically to prevent the legs from swelling. Patients either fabric or rigid. A fabric compres- with complex lymphoedema may be advised to wear a garment overnight.

BEST PRACTICE STATEMENT: COMPRESSION HOSIERY 17 6. HOSIERY APPLICATION, REMOVAL AND CARE

Applying compression hosiery

1. Reach into the compression 2. Turn the compression stocking 3. Pull the compression stocking stocking and grasp the heel inside out at the heel over the foot to the heel

4. Hold the fabric of the outer 5. Lift the fabric up over the heel 6. Use both hands to grasp the layer at the middle of the foot material that is hanging down

7. Distribute the fabric evenly over 8. Lift the fabric up over the knee 9. Check the complete compres- the calf and in stages up to the sion stocking for the correct fit knee and even distribution of material over the limb

Figure 3. Instructions to apply thigh-length medical compression hosiery without a fabric or rigid aid. Images used with permission of medi UK©.

18 BEST PRACTICE STATEMENT: COMPRESSION HOSIERY 6. HOSIERY APPLICATION, REMOVAL AND CARE

Table 4. Main examples of hosiery application and removal aids Fabric applicators Rigid applicators Fabric applicators work similarly to slide Rigid applicators often comprise of a frame sheets. They are made of slippery material with a semi-circular tube to assist with to assist with application of hosiery. They opening the medical compression stocking can be used for open-toe and closed- to allow for easier application. These types toe hosiery, and are compactable and of frames often have long handle options transportable. and may assist those who have difficulty bending forward to and reaching their foot. Miscellaneous: Anti-slip mats: Anti-slip mat to aid application and removal of hosiery Gloves: Rubber gloves with soft interior linings to aid grip during application and removal of all types of compression stockings Roll-on adhesive: Helps hosiery ‘stick’ to the limb and can be washed off with water Rolling compression aids: The hosiery is folded down over the flexible, donut-shaped aid, which is then slid up or down the leg to apply or remove the hosiery.

Hosiery care ness of the garment until the next pre- Patients will largely be responsible for scription. Providing written information keeping their compression hosiery in good that patients can refer to on an ongoing condition, so it is critical that they receive basis is essential. advice to maximise the life and effective-

Hosiery care FAQs

How does the patient clean their medical patient wants to swim wearing hosiery, after compression hosiery? swimming, the hosiery should be taken off, Compression garments can generally be rinsed to remove chlorine or saltwater, and worn for a maximum of 3 days before cleaned and dried as soon as possible. washing. Most compression hosiery can be laundered daily in a washing machine at Should hosiery be worn in the hot summer 40oC; fabric softener should not be used. months? Check with the manufacturer’s information When it is hot, the body may swell more for specific hosiery care. readily; therefore, wearing compression hosiery is required in warmer months and If the compression is laddered, should it still climates. Some compression technologies be worn? have incorporated breathability and climate No, if the compression hosiery is damaged control into their designs, making the limb in any way it loses its structural integrity and feel cool in the summer and warm in the must be replaced. winter. Other techniques, such as spraying cold water onto the garment to cool the limb Can the patient exercise or swim in medical can be effective (the ‘wicking’ ability of some compression hosiery? fabrics will ensure this dries off quickly). Wearing compression garments encourages Check with the manufacturers if you have good muscle pump action, and therefore is questions. very beneficial to wear during activity. If the

BEST PRACTICE STATEMENT: COMPRESSION HOSIERY 19 6. HOSIERY APPLICATION, REMOVAL AND CARE

Skin care under compression CVI, oedema and lymphoedema affect Skin care FAQs the skin integrity, so patients with these conditions have an increased risk of skin When should the patient remove their infection (Harding et al, 2015). Skin care medical compression garments? is therefore a priority for these patients, If possible, the patient can remove their so providing the patient with simple-to- hosiery daily to inspect the skin for any follow instructions on how to care for their breaks, signs of infection (e.g. increased skin at home is integral to supported self- temperature or tenderness) and rashes or management: fungal infections (e.g. tinea pedis), or the ■ Ensure legs are dry before putting on early signs of pressure damage. Particu- medical compression hosiery. lar attention should be given to areas of ■ Avoid applying emollients (e.g. lotions reduced sensation, such as under skin folds or creams) just before application of and between the toes. hosiery, as they can make the garment harder to put on. Applying emollients 20 minutes before medical compression application can reduce the difficulty. ■ Apply skin care products (e.g. emollients, topical corticosteroids) in the evening, after removing hosiery for bed. ■ Check daily for skin changes, including on the legs, toes/nails and space between the toes. ■ Hosiery should be applied first thing in the morning, when oedema is at its low- est levels, to help avoid skin damage and limb expansion. ■ Gently elevate legs when resting to reduce pooling of oedema that can result in skin damage (high elevation is not necessary). ■ Keep physically active to the fullest extent possible, depending on each pa- tient’s specific situation. Follow guidance for ankle exercises for CVI, oedema and lymphoedema if possible.

20 BEST PRACTICE STATEMENT: COMPRESSION HOSIERY REFERENCES

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