It's All in the Stocking

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June/July 2002

By Joy C. Cohn, PT, CLT-LANA, and Anne Lowry, MS, PT, CLT-LANA

Glove and gauntlet compression garments are typically Class I: 20-20 mmHg.

Lymphedema management has changed dramatically in the United States over the past decade as health care professionals have trained in the European techniques known as complete decongestive therapy or complex decongestive therapy. The treatment of this chronic condition occurs in two phases. Phase one is generally intensive (1–5 days per week for 1–6 weeks) including manual lymphatic drainage, skin care, compressive bandaging, and remedial exercises. At the end of this intensive phase of treatment, when the limb has been “decongested” or reduced in volume, the patient is usually fitted with a compression garment to maintain the reduction. This commences the second (or maintenance) phase during which patients use self-treatment techniques as well as compression garments to maintain the reduction achieved in the first phase. Success in selecting and fitting the compression garment is essential to effective long-term control of edema.

External compression reduces ultrafiltration from the vasculature, enhances the musculoskeletal pump, increases the resorption of fluid into the venous and lymphatic system, reduces the local volume in the veins, and helps maintain the limb shape.¹ During phase one, compression bandaging with low stretch bandages allows for a precise fit, readily adapting to the changing shape of the limb. However, bandaging is bulky, time consuming to apply, and unattractive. Garments offer considerably more freedom of movement in a more attractive form.

CHOOSING THE RIGHT GARMENT

Selecting an appropriate compression garment is probably the most challenging task in lymphedema treatment. It is important to begin the discussion of garments early in the course of treatment. It often takes time for patients to adjust to the fact that they will need a garment. In many instances, patients must pay all or part of the cost of the garment, and they will need to plan in advance for the expenditure.

Important factors to consider when choosing a compression garment are: coverage, compression class, appearance, custom-made versus ready-made, material, construction, suspension, skin condition/sensitivity, donning/doffing, and cost and source of payment.

When considering coverage, preventing edema distally or proximally to the garment is important. During the decongestive phase of lymphedema treatment, the therapist will have learned whether, for instance, a bandage to the knee has caused an increase in knee or thigh volume. In that case, the patient will need a garment to the thigh or perhaps to the waist. Usually an arm sleeve will be accompanied by a separate glove or gauntlet to prevent trapping fluid in the hand. Some individuals never experience significant edema in the hand. If therapists back off on bandaging the hand during treatment and the patient does not experience any additional edema, this guides the decision as to whether to order a gauntlet, which just covers the back of the hand, or a full glove with edema control for all of the fingers. Some patients find they can even do without any hand garment, but in our practice, we always order at least a gauntlet since it is very difficult to predict exactly how every patient will respond.

Medical grade garments are available in various compression classes measured in millimeters of mercury (mmHg). These are standardized as:

Class I: 20-30 mmHg
Class II: 30-40 mmHg
Class III: 40-50 mmHg
Class IV: 50-60 mmHg

In a stocking, these numbers are the compression at the ankle with a gradually decreasing compression gradient to the top of the garment. Many ready-made stockings have a higher stretch fabric over the upper thigh called a mantissa. Even garments with the same fabric throughout will give lower compression over a larger diameter body part. Arm sleeves are generally Class I or II, and gloves and gauntlets are typically Class I. Lower extremity garments are generally Class II or III. Additional compression for the leg can be gained by using a higher compression class of garment or by layering a knee-high stocking under or over a longer stocking.

READY-MADE VS CUSTOM

Often the question of a custom-made versus a ready-made garment answers itself. Ready-made garments come in various girths, lengths, fabrics, and compression classes. They are made for a limb of average proportions, although some ready-made stockings do allow for an extra-wide calf and/or thigh. A patient with a disproportionate limb or who needs a higher compression class will require a custom garment.

Ready-made garments are less expensive, quicker to obtain, and easier to replace. They are usually made of relatively thin fabrics with few or no seams, making them cosmetically more acceptable to many patients. Their disadvantages are that they are less precise in fit, are more likely to roll at the top, and may not provide enough support.

Patients are always concerned about the appearance of the garment, particularly when the arm and hand are involved. Some garments are made only in beige, which has a medical connotation to some people, and which does not match the skin tone of darker-complected individuals. A garment may be ideal from a therapeutic point of view, but if the patient will not wear it for cosmetic reasons, it is useless. Sometimes the therapist has to choose a less effective garment that is acceptable to the patient. Some patients prefer a cosmetically desirable garment for public times, and a “workhorse” garment for sport or heavy activity.

FABRIC CONSIDERATIONS

Garments can be made of elastic or nonelastic fabrics. In general, the elastic fabrics are for daytime wear, while nonelastic ones can be worn day or night. Nonelastic garments provide compression by means of a series of hook and loop straps along the length of the garment. The wearer tightens the straps to the appropriate tension. Nonelastic arm sleeves and thigh-high leg garments are well padded with foam. They are comfortable, but too bulky for most daytime activities. Some lower leg garments are thin enough to be worn for walking. Nonelastic garments can be used in place of bandaging by patients who cannot bandage themselves.

The fibers used in elastic compression garments are generally latex rubber, synthetic rubbers, nylon, polyester, cotton, or a blend of these. Some are lined with cotton or silk for comfort. Fabrics can be thick or thin, depending on the fibers used and the amount of compression provided. In general, higher compressions mean heavier fabrics.

In selecting the fabric of an elastic garment, skin sensitivities are a paramount consideration. The compressive force in these garments comes from latex or synthetic rubber, so the therapist must know if the patient is allergic to latex. Most garments containing latex are knitted from a thread consisting of a latex core wrapped with nylon or cotton. A patient or helper at home who is severely sensitive to latex (eg, has a respiratory response to it) may not be able to use garments containing latex. Patients who have only a local allergic response may be able to wear them if an underliner is used.

There are three basic styles of garment construction: circular knit, flat knit, and cut and sew. Circular knit fabrics are seamless, but have a tendency to roll down at the top, especially if the area it covers is very fleshy. This creates a tourniquet effect, obstructing flow of fluid from the limb. In a flat knit garment, a flat piece of fabric is knitted to the patient’s measurements, and seamed up the back. These garments may roll less at the top. In addition, some flat knit garments are made of a coarse-textured fabric, which can provide a mini-massage to the skin, promoting improved fluid uptake and transport. A cut and sew garment is made of several pieces seamed together. More porous fabrics are cooler to wear, an important consideration for patient comfort.

To be effective and comfortable, the garment has to stay in place. Some will stay up by themselves. Some options are a silicone band inside the top edge or a few longitudinal (not circular) stripes of a clear body adhesive. For stockings, a garter belt, suspenders, or an extension of the garment to the waist are available. Arm sleeves can have extensions over the shoulder, which attach to a bra strap or a diagonal strap across the chest.

SKIN SENSITIVITIES

The condition of the patient’s skin will affect the choice of garment. Patients may have wounds or very fragile or sensitive skin. Pulling a tight garment over the skin can cause damage from shearing. In those cases, an understocking (even an ordinary thin nylon) will protect the skin, hold any wound dressings in place, and help the compression stocking slip on more easily. To decrease the friction of donning and doffing, custom garments and some ready-made garments can have zippers. Many patients ask for zippers in the garment. Zippers work well if patients have very narrow ankles or a paralyzed limb. We rarely recommend zippers because they do not eliminate the need to get the garment over the heel, they make the garment bulkier and less attractive, and many patients have difficulty closing the zipper once the garment is fitted on the limb.

For patients who need edema control for both legs, compressive panty hose can be difficult to don. An alternative can be a pair of thigh-high compression stockings with a compression bike pant over them. This arrangement is easier for most patients to manage, and is often more acceptable to men than a panty-hose style garment.

Compression garments are quite expensive, ranging in our area from about $50 for a pair of ready-made knee-high stockings to more than $500 for a custom-made waist-high garment. Some insurers will pay the supplier directly for the garments, some will reimburse the patient for all or part of the cost after the patient pays and submits a claim, but some insurers will not pay anything toward a compression garment. The only garments Medicare covers at present are stockings for patients who have been hospitalized with recurrent ulcers. Insurance plans differ widely and change frequently—another reason to open a discussion with the patient on reimbursment early in the treatment course.

USAGE

Garments are ordered when the patient experiences a plateau in volume reduction, when the limb is not edematous, and in certain instances, for reducing the risk of developing lymphedema. Compression garments are very uncomfortable when applied to an edematous extremity, and they rarely produce significant reduction when used alone.² Measurement for garments should be done as early in the day as possible, when the limb is at its smallest. Treating therapists usually do the measuring themselves, although nontherapist fitters can be used.

Contraindications to the use of compressive garments are:^1,3 acute infections/inflammation, cardiac edema, malignant lymphedema (relative), arterial disease, and acute vascular blockages (superior vena cava syndrome, acute deep venous thrombosis).

Extra precautions should be used in the case of: uncontrolled hypertension; paralysis; insensate limb; diabetes due to the high incidence of small vessel disease; and latex allergy (do not forget that the gloves used to don garments may have latex).

It is very important to educate patients in the proper use of their garments. We have seen many patients who have rejected garments in the past due to difficulty in donning or wearing them throughout the day but who successfully wear them with education. The education should include written and verbal instruction in don/doff procedures (including alternatives), care of the garments, and wearing and replacement schedules.

Donning and doffing are one of the major obstacles faced by many patients due to other conditions that limit their ability to reach their feet or to pull on a garment due to limited hand strength or pain. Rubber gloves and patience in applying the garment in stages are the hallmarks of success. There are several devices available from garment manufacturers that can help the patient get the garment onto the foot and over the heel or hand. These include frames to hold the garment open, slippery covers for the limb, and silicone-based products that make the skin more slippery. Cornstarch has also worked well for us. We avoid powders with talc due to the risk of skin irritation. Most garment manufacturers warn against the use of petroleum-based ointments because the fibers (especially latex rubber) can be weakened by exposure to these products. When patients require a higher compression class than they are able to don easily, we will try layering the garments to achieve effec-tive control.

All garment manufacturers recommend replacement of the garments every 4 to 6 months. The actual interval is based on considerations such as wear due to use, severity of the edema, and type of fabric. Many patients buy two garments to have one to wash while the other is worn. Garment manufacturers include care instructions with their garments. In all cases, we recommend daily washing by hand with mild liquid detergents (for example, Ivory or Dreft) and squeezing gently in a rolled-up towel and hanging to dry.

Finally, patients are encouraged to don their garments as soon as is practical in the morning, when the limb is at its smallest. Many patients alter their lifestyle to shower in the evening so they can don their garments over dry skin first thing in the morning.

Given the long-term use of garments by most lymphedema patients, it is imperative that the treating therapist give a great deal of thought to choosing the appropriate garment and educating the patient in its use. This is crucial to successful treatment of patients with a chronic condition.

REFERENCES

Casley–Smith JR, Casley–Smith JR. Modern Treatment for Lymphoedema. 5th ed. Adelaide, Australia: Lymphoedema Association of Australia; 1997:174-175, 178.
Johansson K, Lie E, Ekdahl J, Lindfeldt J. A randomized study comparing manual lymph drainage with sequential pneumatic compression for treatment of postoperative arm lymphedema. Lymphology. 1998;31:56-64.
Hohlbaum GG, ed. The Medical Compression Stocking. New York: Schauttauer; 1989:56.

Joy C. Cohn, PT, CLT-LANA, and Anne Lowry, MS, PT, CLT-LANA, are certified lymphedema therapists in the lymphedema treatment program at Chestnut Hill Rehabilitation Hospital in Wyndmoor, Pa.

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June/July 2002