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Suppliers of Compression Garments for the Treatment of LymphoedemaJudith R. Casley-Smith This document was last amended on April 2002. This is a list of garments which are available in Australia (for the U.S.A. suppliers see the end of the document; comments about the garments are not repeated but are given in the first, Australian, list). These garments are ones we have found relatively satisfactory, plus some that a number of therapists or patients have used and recommended. There may be others equally as good, but we have not examined them and cannot comment on them. We add comments which have been made about: quality and lasting characteristics, comfort, promptness of supply, compressions and ranges available, etc. The list is divided into the standard, off-the-shelf range and custom, made-to-measure garments. For these one can go to the suppliers or agents listed below, or to one's therapist. Measurements should be made with a narrow tape graduated on both sides of the same surface. Manufacturers have different ways of measuring; be quite sure to do it their way! Obviously, if the therapist, patient, or supplying agent measures incorrectly, the garment cannot work properly. The time of day of measurements and the temperature also make a difference. However, even when the therapist is experienced, inaccuracies may occur when the measurements are transferred to the computer at the manufacturing end. If a garment is almost satisfactory but is either slightly too loose or slightly too tight at one point, a good seamstress can alter it - but the guarantee is voided. If you do have problems with the fit or the garment needs repairs, and you have bought it from a local manufacturer, then it is obviously easier to overcome the problems on the spot. STANDARD ("OFF-THE-SHELF") GARMENTS If a patient can be correctly fitted with a standard garment, this is preferable and alleviates the risk of the garment arriving made to incorrect measurements. The measurements of the garment MUST correlate very closely with those of the patient. Otherwise, the garment may cause a tourniquet effect in one or more places - thereby limiting lymph flow. It can cause quite severe damage. Alternatively, it may be far too lax in some parts and allow bulges to form. If there is a serious discrepancy in even one parameter, another make must be used, or a custom-made garment. With lighter grades, two garments (one over the other) are needed to maintain reductions after C.P.T. "Classes" and the pressures in mm Hg they provide vary with manufacturers. Measurements for, and the supply of many brands (Jobst (Elvarex), Juzo, Medistrumpf, and Sigvaris) can be made at: Cosmac (St. Vincent ‘s Private Hospital Pharmacy, 406 Victoria St, Darlinghurst, Sydney, NSW 2010, (02) 8383 7257 & 18 Ross St., North Parramatta, NSW 2151, (02) 9630 2966, fax (02) 9890 1654); or at O.P.C. (151-159 Turner Street, Port Melbourne, Victoria (03) 9681 9666, Fax: (03) 9681 9366, email: sales@opcpl.com.au. BSN – Jobst Inc. – now supply Elvarex and Jobst garments. Manufacturer: Jobst (Beiersdorf) GmbH, Emmerich, 46446 Germany; 49+(282) 260 70; fax: 49+(282) 260 199 Australia: Smith & Nephew, Customer service no. 1800 772 577, 315 Ferntree Gully Rd, Mount Waverley, Vic, 3149 (Can be measured-for at: Cosmac Surgical or O.P.C – see above) USA: Jobst, 5825 Carnegie Blvd, Charlotte, NC 2809-4533, USA; 704 554 9933; fax: (419) 691 4511 www.jobst-usa.com The range includes 3 different arm styles, 2 leg styles and 2 styles of gloves. Fabric: cotton covered, flat knitted with a seam. Compression: sleeves, Class 2 (30 mm Hg); stockings Class 3 (40 mm Hg) There is not a large ranges of sizes or styles; the sleeve will only fit a fairly bulky shoulder, not a finely built person. They are very comfortable to wear. However there have been some problems with obtaining the garment which was ordered. Garment life is excellent. They also supply glue, moisturiser and stocking washing liquid (Jolastic - Jobst). Jobst (USA) - also known as Vairox (Jobst) Manufacturer: Jobst, 5825 Carnegie Blvd, Charlotte, NC 2809-4533, USA; 704 554 9933; fax: (419) 691 4511 www.jobst-usa.com Australia:Smith & Nephew Australia, 1800 772 577, 315 Ferntree Gully Rd, Mount Waverley, Vic, 3149 Synthetic material, seamed, shaped, legs only, open toes. Pressures 30-40 or 40-50 mm Hg. We believe the German Elvarex (above) are superior. Jobst Pre-sized Gloves. Manufacturer: Jobst, 5825 Carnegie Blvd, Charlotte, NC 2809-4533, USA; 704 554 9933; fax: (419) 691 4511 www.jobst-usa.com Australia: Smith & Nephew Australia,1800 772 577, 315 Ferntree Gully Rd, Mount Waverley, Vic, 3149. Two styles (standard or adjustable with velcro) and 6 sizes are available. GloriaMed Manufacturer: Gloria Maglieria Elastica srl, Via Diaz, 7 – 22017 Mennagio (Co), Italy Australia: Cosmac Surgical Appliances Pty Ltd, PO Box K314, Haymarket, Sydney 2000, Ph: (02) 9211 5733 Fax: (02) 9281 4863, Email: info@cosmac.com.au Measuring and Fitting: Cosmac Surgical, St. Vincent’s Private Hospital Pharmacy, 406 Victoria St, Darlinghurst, NSW, Ph: 8382 7257 or Cosmac Surgical, 18 Ross St, Parramatta, NSW, Ph: 9630 2966. GloriaMed Range: GloriaMed manufacture only medical stockings, not sleeves/gloves. Stockings Class 1, 2 and 3 in all styles. Available in either nylon or cotton fabrics. Class 2 & 3 stockings also available in natural rubber stretch. Extremely comfortable stockings suitable for all conditions. Prices are very reasonable There is a large range of standard sizes available, with both normal and wide fittings, and short and long fittings. Manufacturer: Julius Zorn, Juliusplatz,
D-86543, Aichach, Germany; 49+(8251) 901 111; Australia: Appliance
& Limb Centre, 16 Cope St., Redfern NSW 2016; (02) 9319 1955; U.S.A.: Julius Zorn Inc., Box 1088,
80 Chart Rd., Cuyahoga Falls, Ohio, 44223-0088; Sleeves compression: Class 1 (20-30 mm Hg), Class 2 (30-40 mm Hg). Fabric: synthetic (including silk inside making them good for sensitive skins). Varin Soft-in or Varin Soft-in Silk (particularly comfortable). Good shoulder fit for most people. Max sleeve: standard wrist measurements but larger upper arm section, there is also an extra small sleeve (in Varin Soft-in Class 2). Separate hands (with thumb stub – Class 1, or finger and thumb stubs – Class 2) are available in Helastic. Stockings, compression: Class 1 (25 mm Hg), Class 2 (35 mm Hg), Class 3 (45 mm Hg). Wide range of styles, including for maternity, fair range of colours. Fabric: good variety, synthetic, cotton or silk covered fibre. Wide colour range in Hostess (sheer - synthetic and very fine, Class 1 & 2). Varin ranges are very comfortable and easy to don. Good for patients with sensitive skins. A measuring service in a number of areas – contact the Supplier. Manufacturer: Medi Bayreuth, Waldsteinring 6, D-95448 Bayreuth, Germany; fax 49+921 91 257 Australia: Reis Orthopaedic
Services, 25 John St., Lidcombe, NSW 2141; (02) 9643 1444, U.S.A.: Medi USA, 78 W. Seegers Rd.,
Arlington Heights, IL 60005; (1800) 633 6334; Compression: Class I = 20-30 mm Hg; Class II = 30-40, Class III = 40-50 (Class IV,= 50-60, is made-to-measure only). Fabric: synthetic; Range: a number of styles available. They also make a combined arm with mitten sleeve in Classes I & II. Sigvaris Manufacturer: Ganzoni, Groblistrasse 8, CH-9014, St. Gallen, Switzerland; fax 41+712 74 29 29 Australia: Morris Surgical, GPO Box 9, Brisbane, Q 4001; (07) 3357 5944; fax (07) 3857 0031. U.S.A.: Sigvaris, Box 570, 32 Park Drive E., Branford, CT 06405; (800) 322 7744, fax (203) 481 5488 Fabric: synthetic with natural rubber. Compression: Class 1 (801)= 20-30; Class 2 (503) = 30-40, Class 3 (504) = 40-50, Class 4 (505) = 50-60. This is a very good, graded compression-garment. They have the widest range of styles and sizes, with good wearing capabilities. We usually find them very satisfactory. They also supply good gloves for donning the garments and glue for sticking them to the skin if necessary. There is sometimes a problem with 'banding' at the wrist and toes. This should not occur if measurements are really correct. N.B. the length of the longest stocking has been reduced, so do check it is adequate. They now make an arm sleeve with a mitten (hand plus thumb piece) attached. This is the only one, that we are aware of, in standard garments. The 902 sleeve is ideal for prophylactive use for a patient without lymphœdema, but at risk, when flying. They now have a new range of sheer compression stockings Glamour in C1, 1-2, with proven compression in a good range of colours, ranging from extra small to large with a waist size up to 110 cms. This range includes pregnancy stockings as does their Delilah C1.1 range, which come in a good range of colours as well. Varisma (Viso Medical) Manufacturer: Viso Med., 2072 St. Blaise, Switzerland; 41+(32) 753 22 12; fax 41+(32) 753 43 94 Australia: Bar Med, 408 High St., Northcote,
VIC 3070; (03) 9486 7770, (1800) 803 662; Varisma come in compression classes 1-3 (class 3 = 36-45 mm Hg). Fabric: cotton next to skin; good colour range in Varisma Class 2 only. These are cool since only cotton is in contact with the skin, so they are very comfortable to wear. A wide range of styles is available. They have good graded compression and wearing capabilities. A program (in Lotus Version 2.1) to aid in choosing is available. Viso have released a new range of stockings made from Lycra cotton and Microfibres. Compression class 1,2,3 and 4 (49 + mm Hg) These are lighter and finer than Varisma. Venosan Manufacturer: Salzmann, Unterstrassse 52, St. Gallen, CH-9001 Switzerland, 41+(71) 228 43 13; fax 41+(71) 228 43 10 Australia: Biomet, P.O.Box 348, North Ryde, NSW 2113; 1800 251 201, (02) 9878 6100, fax (02) 9878 6473 U.S.A.: Venosan North America, 718 Industrial Park Ave, P.O. Box 4068, Asheboro, N.C. 27204/4068; (910) 672 6062; fax (910) 672 3969. Venosan 2000 cotton blend, 100% cotton on skin breathes well, cool to wear. Extra sizes for big calf and large thigh measurements. All styles available off the shelf. Compression up to 49mmHg. Arm-sleeves standard sizes available up to 50mmHg with strap, wrist and hand extension. Travel arm-sleeves very reasonably priced 25-32mmHg. New (4000) range/high tech micro fiber, very soft, very cool, easy don up to 36mmHg+. All styles, comfortable on skin under heavier garments, as self wicking, helps to keep swelling down during the night. All colours in stock. Venosan have produced a new 5000 range, C1. 1-3 (18-21, 23-32, 34-46 mm Hg) with silver fibres woven into the stockings. They are available from small to extra large. The silver has antibacterial and antifungal properties. They also supply a shear support stocking c1. 1-2. Vikora Pressure Gloves Manufacturer: Vikora, PO Box 44, Wahroonga,
NSW 2076, Australia; ph (02) 9487 6730, fax (02) 9487 6740, USA: toll-free fax: 1888 245 7090; Canada 1888 291 8719 Fabric: synthetic, very soft and durable. Sizes: children 4-7, 8-12 yrs plus ranges of sizes in women’s and men’s. Extra-large fingers can be accommodated. Choice of glove lengths. The fingertips can be cut off without the fabric "running" or preferably with a glove worn inside out over another for extra pressure. These are extremely reasonably priced. CUSTOM-MADE(Check how measuring should be done; it varies with the supplier!) When ordering Elvarex custom-made stockings and perhaps other custom-made ones, the "H" (heel) measurement should be taken with the foot flexed to make a 90° angle with the front of the leg. The tape runs from just under the heel just below the malleolus. If a great deal of reduction has been achieved just above the ankle and extending up the lower leg, the fit and compression gradient of the garment will be much better if the "B" measurement is taken up to 10 cm proximally. Barton-Carey Manufacturer: Barton-Carey, PO Box
421, Perrysburg, OH 43552, USA; ((1800) Australia: Vikora Medical Distributors PO Box 44, Wahroonga, NSW 2076, ph (02) 9487
6730, fax (02) 9487 6740, There is a complete range of styles and colours. Fabric: Spandex (nylon) which should be cooler to wear than heavier garments. Compression: up to 50 mm Hg. They have a simplified measuring technique. They are posted (Federal Express) two working days after receipt of order. They are amongst the most reasonably priced on the market. Elvarex (BSN-Jobst Inc.) Manufacturer: Jobst (Beiersdorf) GmbH, Emmerich, 46446 Germany; 49+(282) 260 70; fax: 49+(282) 260 199 Australia: Smith & Nephew Australia, 1800 772 577, 315 Ferntree Gully Rd, Mount Waverley, Vic, 3149 (Can be measured at: Cosmac Surgical or O.P.C – see above) U.S.A.: Order directly from Jobst, Germany (above). Compression: up to 60-70 mm Hg. These are a seamed, but shaped, garment. Allow 10 days from ordering before delivery. They have a good life-span - patients say about 6 months at least and that they are very comfortable to wear. They 'breathe' well. They are similar to the standard range, but made to order. They will try to accommodate special requests and will make (e.g.) one leg of a higher compression than the other. Jobst (USA) (BSN-Jobst) Manufacturer: Jobst, 5825 Carnegie
Blvd., Charlotte, NC 2809-4533, USA; (704) 554 9933; Australia: Smith & Nephew Australia, 1800 772 577, 315 Ferntree Gully Rd, Mount Waverley, Vic, 3149 Synthetic material, seamed, but shaped. Many design modifications possible; special requests catered-for (e.g. lining around certain areas). Pressures: 20 - 50+ mm Hg. Delivery 5-10 days. We believe the Elvarex ones (above) are superior. U.K.: BSN-Jobst Helathcare House, Goulton St Hull, HU3 4DJ, Ph 44 (0) 1482 222200, fax 44 (0) 1482 673081 GloriaMed Stockings(see Standard Garments) are also available as custom made. Delivery is two weeks. Juzo Manufacturer: Julius Zorn, Juliusplatz, D-86543, Aichach, Germany;
49+(8251) 901 111; Australia: Appliance & Limb Centre,
16 Cope St., Redfern NSW 2016; (02) 9319 1955; U.S.A.: Julius Zorn Inc., Box 1088,
80 Chart Rd., Cuyahoga Falls, Ohio, 44223-0088; Compression, Sleeves: Class 1 (20-30 mm Hg), Class 2 (30-40 mm Hg), Class 3 (40-50 mm Hg); Stockings: Class 1 (35 mm Hg), Class 2 (45 mm Hg), Class 3 (60 mm Hg). Fabric: synthetic, silk or cotton covered. Wide range of styles, including for maternity, fair range of colours. Varin Soft-in or Varin Soft-in Silk, Hostess (sheer - synthetic and very fine, Class 1 & 2) plus special models in silk or cotton (Class 1 & 2). Varin ranges are very comfortable and easy to don. They are recommended for patients with sensitive skins. Helastic/cotton gloves or gauntlets (finger lengths as required). Medistrumpf Manufacturer: Medi Bayreuth, Waldsteinring 6, D-95448 Bayreuth, Germany; fax 49+921 91 257 Australia: Reis Orthopaedic
Services, 25 John St., Lidcombe, NSW 2141; (02) 9643 1444, U.S.A.: Medi USA, 78 W. Seegers Rd.,
Arlington Heights, IL 60005; (1800) 633 6334; Compression: Class I = 20-30 mm Hg; Class II = 30-40, Class III = 40-50; Class IV,= 50-60. Fabric: synthetic. A number of styles available Sigvaris Manufacturer: Ganzoni, Groblistrasse 8, CH-9014, St. Gallen, Switzerland; fax 41+712 74 29 29 Australia: Morris Surgical, GPO Box 9, Brisbane, Q 4001; (07) 3357 5944; fax (07) 3857 0031. U.S.A.: Sigvaris, Box 570, 32 Park
Drive East, Branford, CT 06405; tel (800) 322 7744, In Australia, at present these are only available direct from Morris Surgical. Supply takes 10-14 days and the cost is about a 80% surcharge on the standard range. They are of a similar quality to the standard range. So far the garments have proved to be very satisfactory. They are knitted, with no seam. Their sizes will cover from about 12-35 cm at the ankle , with the thigh going up to 96 cm. The range covers all styles in the 503, 504 and 505 series, from just calf to full pantyhose. Full-body garments are not available. The arms are in the 504 range, in the standard styles, with or without gauntlet. Second Skin 4th. Floor, 251 Adelaide Tce., Perth, WA 6000; (09) 325 7055; fax (09) 325 7066. Fabric: synthetic. Compression: unknown - possibly about Class 2 of Sigvaris. Not suitable for use for other than the lowest pressures. Any style, including full body suits can be made. Much effort is put into making the garments comfortable and æsthetically pleasing. These seem only suitable for mild lymph-œdemas of the arm, or in a child after C.P.T., or for helping to control the size of the limb without C.P.T. Varisma (Viso Medical) Manufacturer: Viso Medical, 2072 Saint Blaise, Switzerland; 41>+(32) 753 22 12; fax 41+(32) 753 43 94 Australia: Bar Med, 408 High St., Northcote, VIC 3070; Tel (03) 9459 0322, outside Vic: 1800 803 662; Fax (03) 9459 0499. Agents in all states. Will make custom-made up to Class 3 (36-45 mm Hg) - see Standard Range. Delivery to Australia is 3 weeks. Cost is twice the standard. Venosan Manufacturer: Salzmann, Unterstrassse 52, St. Gallen, CH-9001 Switzerland, 41+(71) 228 43 13; fax 41+(71) 228 43 10 Australia: Biomet, P.O.Box 348, North Ryde, NSW 2113; 1800 251 201, (02) 9878 6100, fax (02) 9878 6473 U.S.A.: Venosan North America, 718 Industrial Pk Ave, PO Box 4068, Asheboro, N.C. 27204/4068; (910) 672 6062; fax (910) 672 3969. Venosan 2000 cotton blend available in all styles for legs and arms. Arm-sleeves with hand extension and thumb, heavy duty, durable, ointment resistant. Compression up to 49+mmHg. Full knit to groin, pantyhose special request for individual compression on each leg. Excellent quality very reasonably priced. 1000/4000 range class 1 and 2 (18-22mmHg and 25-32mmHg) available in all styles for legs only. Maximum 10 days on all made to measure. Venosan garments carry a 6 month warranty on compression and manufacturing faults. Venosan 5000(the magic of sliver) range is available made to measure in classes 1,2 and 3. This 100% Cotton and Silver next to the skin, in 7 styles. All styles have either open or closed toes. Arm sleeves are also available with a Silicone band. There are anti bacterial and bioactive as well as heat conductive and temperature regulatory. Please allow ten days for delivery. IndiaNorma D.N.D. Products, Norma Complex, D.D.A. Market, J-Block, Vikas Puri,
New Delhi - 110 018 Sr. Marie Doolan is an excellent Compression Therapy Consultant and Educator (310 Nicholson St., Fitzroy, VIC, Australia; Ph (03) 9486 9738, fax 9486 9850, email srmdln@aol.com). She has trained the following people in garment design , change and manufacture. Janet Milne, PO Box 677 Traralgon Vic 3844 Ph (03) 5174 6863, Jenny Jensz, 5 Victoria St, Hamilton Vic 3300, Ph (03) 5571 0390, Rachel Friebel, 43 Tyne Street, Box Hill North, Vic 3129, Janice Pekin, 64 Oberon Drive, Belmont, Geelong Vic 3216, Ph (03) 5244 2871 Kay Porter, Compression Garment Alterations 144 Fairy St. Warrnambool
3280, Ph (03) 5562 7607 ADJUSTABLE GARMENTS While these are expensive, $(US) 250-400 (Standard) to over $(US) 1000 (Custom-made), because they last much longer than bandages or other garments (and can be adjusted as a limb reduces further), they are cheaper in the long-term. This, plus their ease and speed of application make them a very attractive alternative, particularly for night use. They will also give extra pressure if needed over an existing garment. Both only obtained from the USA. CircAid Manufacturer: CircAid, 9323 Chesapeake
Dr., Suite B1, San Diego, CA 92123, USA; Both sleeves and full-leg garments. These adjust circumferentially every few cms with adhering tapes. An undergarment of some kind, e.g. a Tricofix sleeve, is essential since they must not be worn next to the skin. Foam pads can be used in difficult areas, e.g. ankles or elbows, and for protection. The Reid Sleeve Manufacturer: Peninsula Biomedical, 4340 Scotts Valley Dr., Suite
1, Scotts Valley, CA 95067-6149, USA; A very comfortable adjustable garment. Particularly suitable for use at night, since it is a little bulky because of padding. Sleeves and stockings available. Arm Assist™ and Leg Assist™ is another adjustable
compression garment which could take place of bandages at night in a similar
way to the Circaid™ and the Reid Sleeve. It is very reasonably priced.
Available in the U.S.A. from MedAssist Group, 1 800 521 6664 (Restorative
Products Inc., 930 Florida Ave., Palm Harbour, FL 34683). 1.Blistering, abrasions and ulcerations: Is the size correct? Is the application correct? 2.Pressure points may be caused when the radius of curvature of the limb is small (e.g. across lateral metatarsal/tarsal joints). Small foam pads may be slipped in at both sides to prevent this. 3.Impairment of arterial supply and/or venous return (are toes or fingers blue?): Is choice of garment correct? Does it stop at the metatarsals/metacarpals and exert too much pressure on the blood vessels? Is the measurement correct? 4.Pain in leg, increasing rather than decreasing
with walking: Is there arterial insufficiency? 5.Regression of skeletal growth in a still-growing patient: In children, be very careful that the garment is correctly measured and made. Check that they do not outgrow it. Major European garment factories manufacture the thread, fabric and garments themselves and of course sell them under their own brand names. They have worked hard to fill a large gap in our supply to patients. They also produce a range of styles that suit most people. Most importantly, they produce the correct compression for lymphœdema, particularly after treatment with C.P.T. With the limited fabrics available in Australia for local manufacturers, it has been very difficult to attain the high compressions necessary for lymphœdema. Unfortunately with these garments, extra compression can only be obtained by making the garments smaller - or by wearing two garments, one over the other. This is also sometimes necessary with the European garments in order to maintain, e.g., a large leg reduction. These may also be easier to put on than a single stocking of very high compression, particularly for an older person. Garments for ChildrenA child will not need as heavy a compression as many adults. It should also be noted that with lymphœdema in one leg and a very little in the other, different compressions are needed. E.g., possibly, Grade 5 on the bad leg, Grade 3 on the other leg and Grade 2 around the abdomen (with pantyhose). These variations must be clearly requested on your order form, as must any special requirements. Therapists and patients should also realise that a garment of lower compression must be used if the patient has not been treated with C.P.T. A class with 50-60 mm Hg compression is too high for them. Be careful about garments from doctors who do not understand C.P.T. and lymphœdema, and are used to treating varicose veins. They almost always prescribe far too short a garment (e.g. calf length instead of the full thigh needed for lymphœdema ) and of far too low a compression for containment of treatment or size of limb. If a therapist or hospital is reduced to using something like Tubigrip™ as compression then the K.T. KompriNET™ is a very much better alternative as it does not have circular elastic every few mms which constrict what lymphatic flow may exist at the very superficial level. VITAL POINTS ABOUT COMPRESSION GARMENTS Treatment for lymphœdema is a continual process. It is not cured by one course of treatment. While the 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 the garment, must be changed and washed at least every couple of days. Apart from the necessity for cleanliness, this will restore their elasticity. 3.Care must be exercised when putting on bandages or garments. Putting on and adjusting the garment should always be done when wearing rubber gloves with patterned finger grips. 4.Garments must be replaced if they lose elasticity; or if they or bandages are damaged. 5.At least two sets of bandages and 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. Do not dry in the sun or a heated 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 or garments. 11.Rinse the garment if wearing it during swimming in salt or chlorinated water. 12.If a cream must be used under a garment to improve the suppleness of the skin, use a water based one, such as Hamilton’s Dimethicream or Nivea. 13.Patients must realise that they can get sunburnt through garments, particularly the synthetic ones. Appropriate measures must be taken to avoid this. THE MAINTENANCE OF TREATMENT MUST BE A PATIENT'S OWN RESPONSIBILITY! |