Compression Garments
for the Treatment of Lymphoedema
Judith R. Casley-Smith
Compression garments and compression
bandages, are probably the most difficult problem we have had in the
maintenance and control of lymphoedema before, during and after treatment.
These are not yet completely solved. However the situation is a great
deal better than it was in 1987 in Australia , when we introduced Complex Physical Therapy (C.P.T., Complex Lymphatic or Lymphedema Therapy - C.L.T.). They are absolutely essential
for maintaining the great reductions achieved by this combination of treatments.
Compression garments are necessary
1. to prevent lymphoedema occurring or increasing,
2. to try to maintain the size of the limb when treatment is unavailable
or unaffordable,
3. to maintain the reduction achieved after treatment, and to continue
the remodelling of the limb.
1. Prophylaxis - Prevention of Lymphoedema
If a limb is a risk (e.g. after a mastectomy, operation for melanoma,
etc.) then a correctly fitting garment should be kept on hand for immediate
wearing, e.g., after an injury, during an aircraft flight (even for just
one hour!), or excessive work causing aching and leading to swelling,
etc. Prevention is of the utmost priority, because it is much easier to
prevent lymphoedema than to treat it! However the garments in this situation
should be no more than 30 mm Hg for arms and 40 mm Hg for legs (much higher pressures can, and should be used after a course
of C.P.T.
2. Garments used as the only Treatment
If no other treatment is used, good compression garments will limit the
amount of swelling and thereby slow the advancement of lymphoedema. Some
patients even get reductions in their limbs using just such garments and
the L.A.A. exercises. However, this is far from the ideal.
Again, the pressure must be less than if the limb had been reduced with
(C.P.T.).
3. After Therapy
For reasons already mentioned, these are essential after C.P.T. If patients
do not wear and maintain garments correctly they
just throw time, effort and money away!
The Choice of a Garment
Availability is almost as important as efficacy. There is no point in
treating a patient by C.P.T., and then having to wait weeks for a suitable
garment to arrive. A patient, alone, is often not able to bandage themselves
as is done in the clinic (especially post-mastectomy patients). In fact
it is hard enough for some to put on a pressure garment. This means that
the choice of appropriate bandages and sleeves/stockings depends very
greatly on good suppliers. If the garment has to be custom made, it is
helpful to have a local seamstress who can do any fine alterations necessary. (However if this is done the garment guarantee is often invalidated.)
Once a therapist is experienced, they find that almost all of the reduction
occurs in the first 7-10 days. When they are confident of this, a suitably-fitting
garment may possibly be ordered at this point if a made-to-measure one
is required. In this regard, it is essential that measurement of the patient
in the clinic or by a supplier is done absolutely correctly. Mistakes
can be made, but it should not be the patient who has to bear that cost.
Choice is also limited by whether a patient can actually be fitted with
a ready-made garment, or whether they need a custom-made one. Children
and many patients with primary lymphoedema can only be fitted with custom-made
ones. Use of a regular (standard) garment is advised if the patient correctly
fits the measurement parameters. This overcomes the possibility of mistakes
in the size or fit of a made-to-measure garment; it is also cheaper. We
stress that the regular garment must fit correctly and
comfortably. However a made-to-measure garment may be still more comfortable
to wear.
The quality of the fabric is also important. These garments must last
at least 4 months. They need to be changed and washed daily, especially
in a hot climate. Patients must follow the manufacturer's washing instructions
and should never allow them to dry in the sun or in a drier. Jobst-Beiersdorf supplies Jobst 'Jolastic' a special washing solution for elastic
garments, but there are other suitable mild detergents.
Patients must be shown how to put on the sleeve/stocking
so as to cause minimum stress on it. Rubber gloves with a raised pattern
on the finger tips should be used. (Sigvaris supply these,
or certain washing-up gloves are suitable.) Such gloves will:
- protect the garment from fingernails, rings, etc.,
- make them easier to get on,
- allow the garment to be adjusted evenly over the limb and fit it correctly.
Care must be taken in the use of skin preparations when wearing a garment.
Although some have been recommended for use under garments (Com-pat
Body Lotion - Jobst), the manufacturers do not guarantee that they
will not affect the life of the garments. Of course wearing a bandage
at night allows suitable skin care products to be used easily.
We also stress the importance of skin care. Be aware of the list of products from Hamilton Laboratories and from certain
other manufacturers. Particularly recommended are: Hamilton's Body
Wash, plus Shower Oil as a moisturiser. These are much preferable
to soap for lymphoedema. Other useful products are: Dimethicream or Skin Repair for general moisturising, Urederm for the
treatment of chronic dry skin and Dermex 7A as a protection and
moisturiser while swimming or during hydrotherapy in pools. Castellani's
Solution can be used on any moist 'folds' (ask your pharmacist for
it); 'Minidine' also works well. Remember protective sunscreens. Lodema (coumarin) powder is very good under a garment. Lodema (coumarin) ointment can however only be used under bandages or if a garment
is not used at night; it is also good for bites, stings cuts, burns or
bruises.
The comfort, and therefore the patient's compliance, is of great importance
for maintaining the gains made during therapy. Hence much depends on the
fit of the garment and the material used.
Some patients have allergy problems to synthetic materials and a cotton
coating of the elastic fibres is then very important. Some garments 'breathe'
more than others, giving greater comfort and compliance. A new garment
may cause pressure or irritation at a joint or under the arm; a lining
in the garment at this point or powder or a smooth adhesive dressing (e.g.
'Fixomull', Jobst) may alleviate this.
It is useful for the patient to wear the garment for the last few days
of treatment so that all the above problems can be checked. It will also
give a good indication as to whether the compression is adequate. If not,
a second, lower grade, over-garment will be needed also.
A number of patients need gloves or mittens. The gauntlet variety (i.e.
attached to, and part of the sleeve) are preferable in that they reduce
the risk of a pressure band at the overlap. This is difficult with a stocking.
Separate bandaging of the toes and distal part of the foot may be needed.
Garments should be able to be worn easily and stay in place without slipping.
A woman with a prosthesis often cannot maintain an arm sleeve in place
with a support strap attached to her bra strap on that side. It may be
more comfortable to wear a chest garment incorporating a bra and sleeve,
joined with a slit under the arm to allow for breathing and perspiration.
A wide strap around the chest below the other breast may work.
Many bands used on garments are too narrow to be comfortable and need
to be replaced by something wider. Similarly, a waist band to support
a leg stocking may slip - allowing the stocking to slip down. In this
case a pantyhose arrangement, with one leg cut off (if only one is lymphoedematous)
and a slit at the crutch, feels more secure and a lot more comfortable.
After a mastectomy a well fitted bra should always be worn. The straps
should not cut into the shoulders, nor should wire under a cup cause red
lines or indentations. These will both restrict lymphatic drainage. Realize
that the opposite breast is also 'at risk' of swelling due to overloading
of the natural collateral drainage. Similarly with a lumpectomy plus radiotherapy,
the breast on which this was performed is also 'at risk' and should be
properly supported.
There are solutions available which have been specially made to stick
the garment to the limb (e.g. 'It Sticks!' from Jobst and 'It
Sticks' from Sigvaris). These must be used with care and applied as
a number of vertical stripes. If they are applied horizontally in
a ring around the limb, they can shrink as they dry. They pull the
garment with them and so cause a band of excess pressure at the top of
the limb, which will restrict lymphatic drainage. So be careful!
One needs to be wary of a stocking or sleeve that stops too short of
the top end of the limb, or that causes a pressure band at that (or any
other) point. This will reduce lymphatic drainage as well as causing a
band of fibrous tissue to form which also later reduces this.
Patients also need to be aware of the amount of exercise that
they should do. If too much is attempted, the limb will swell further;
then the garment becomes uncomfortable. The patient then feels it is too
tight and so takes it off, then the limb swells still further and a new
garment is required of a larger size! Some patients also like to remove
their garments for long periods of time (e.g. at night). Then the limb
again swells and the patient feels that the garment was the wrong size
and may wrongly blame the clinic or the supplier!
These principles also apply to the treatment of acute injury and to oedemas (usually lymphoedemas) caused by paralysis or confinement
to wheel chairs.
Similarly, venous oedemas (including chronic venous insufficiency and during pregnancy) should be treated with compression stockings,
but of a lower grade (18 - 48 mm Hg is usually recommended by the manufacturers
and therapists).
Patients with a lympho-venous shunt, diabetes or arterial
insufficiency can only tolerate a garment with a lower pressure than
usual. This also applies to untreated patients.
If a patient finds it too difficult to put on a high compression garment,
then two lower compression ones - on top of each other - may be preferable.
But a 40 mmHg plus a 30 mm Hg one do NOT give 70 mm Hg,
but approximately 55 mm Hg.
For lymphoedema of the leg, unlike for chronic venous insufficiency or
varicose veins, a full thigh-high stocking is essential to prevent just
pushing the lymphoedema above the knee. In venous oedema, a calf stocking
of lower pressure is sufficient unless lymphoedema is also present.
When choosing a garment or sock, it is very important that it does not
cause constriction just below the knee - thus preventing drainage and
leading to swelling. Some socks are not long enough for taller people
and slip when walking; if so, get one that comes to mid-thigh (which will
also alleviate the problem of a 'tourniquet' effect below the knee.
Good communications and suggestions between the patient and therapist,
and between the therapist and the supplier are essential to provide the
best possible service for the patient. Pressure sometimes needs to be
applied to the manufacturer to actually supply the patient's need and
thereby to give an efficient service. A patient with problems should always
return to their therapist. Analgesics should never be taken just to overcome
constant pain from an ill-fitting bandage or garment. Manufacturers try
hard to accommodate customer requirements, but need feed-back to understand.
An excellent book for for doctors and therapists who wish further more
detailed information is:
Hohlbaum GG. The Medical Compression Stocking. Stuttgart
& New York, Schattauer, 1989.
Vital Points on Compression Bandages and Garments
Treatment for lymphoedema is a continual process. It is not cured by one course of treatment. While a therapist can reduce
the swelling initially, the patient is responsible for maintaining
that reduction. What follows are a few simple rules, all are vital!:
1. The bandages or garments must be worn all day and all night.
2. Each set of bandages, or a garment, must be changed and washed at least every couple of days.
3. Care must be exercised when putting on bandages or garments.
4. Bandages or garments must be replaced if they lose
elasticity or are damaged.
5. At least two sets of bandages or garments must be owned.
6. Order a new garment well before an old one has worn out.
7. The manufacturer's washing instructions must be followed
and they must not be dried in the sun or in a drier.
8. The therapist must be consulted if a limb
becomes painful or discoloured (e.g. blue toes), or
if a garment chafes or is too loose or too tight.
9. Nights are more restful if the patient changes bandages or garments
before sleeping.
10. Wash the limb thoroughly when changing bandages.
MAINTENANCE OF TREATMENT MUST BE THE PATIENT'S OWN RESPONSIBILITY |
