In January’s blog, we said there are a number of factors that need to be considered when deciding whether to go the traditional route for long-term compression (i.e. hose or sleeves) or use an alternative. In this blog, we will finish our introduction by discussing some of these considerations.
The Reason for Swelling
The first area of consideration when choosing compression is the underlying reason for the swelling. Is the type of swelling pure lymphedema (i.e. swelling caused from an incompetent lymphatic system) or is the swelling due to impaired venous flow (i.e. venous insufficiency, paralysis, dependent positioning, DVT, etc.)? Flat-knit, custom garments are the recommended compression for lymphedema.1 This is because of the high pressure required & the extent & form of swelling. Flat-knit provides a high working pressure & a lower resting pressure. This is ideal when a person begins exercising or walking as the garment works against the tissue to facilitate lymph fluid movement. Velcro options will maintain volume loss & may even facilitate drainage (some therapists use Velcro compression in place of bandaging during treatment, though this is not standard treatment & will not yield maximum results). While such an option can be convenient & cost-effective, it is not without downsides (such as bulkiness & numerous straps on longer garments that can become cumbersome, etc.). Velcro options are not superior to flat-knit, custom garments for pure lymphedema, but they are an alternative in some cases.
For others who have more of an edema-related swelling* (when the lymphatic system isn’t incompetent, it is just overwhelmed by the added volume caused by an impaired venous system), circular-knit stockings (& some Velcro products) are a good option. Circular-knit work differently than flat-knit. Circular-knit have a low working pressure & a higher resting pressure which is primarily needed in cases of venous ulcers. In other localized edema conditions, elevation alone may resolve swelling but compression can provide comfort during sitting/standing times.
*It is important to note that generalized swelling (swelling throughout the body) is more likely an indication of a medical condition that could potentially be very serious. Medical treatment, not compression, is the appropriate intervention in this case. See blogs from March, August, November & December of 2014 for additional information.
The Required Style
Another consideration is the style or length. A good rule to follow is if there was swelling in an area before bandaging, then a garment needs to cover that area to prevent refilling when the bandaging phase is complete. For example, if a person has swelling in the leg that is present from the foot to above the knee, knee-high compression isn’t sufficient. If knee-high compression is chosen, swelling will inevitably return to above the knee.
The Location of Swelling
If swelling is present in the face or arm, for example, a garment will need to be custom-made & usually flat-knit. However, flat or circular-knit can be made in custom.
Some garments can be made with silver, an anti-microbial agent which may reduce infection risk. If recurrent infections are an issue, most likely other factors need to be addressed such as environmental hygiene, adherence to lymphedema precautions, unresolved swelling, compliance with previous compression, appropriateness of previous compression garment, etc.
Day vs Night Compression
Lymphedema patients typically require night compression. In such case, wearing hose or sleeves is not recommended. The primary concern is the compression level. Higher compression is tolerated & needed during the day, but less is needed at night in a recumbent position. There is a risk of ischemia (lack of blood flow) to an area if day garments are worn at night. Bandaging is the recommendation for night compression but some patients cannot do bandaging themselves & do not have assistance. Others simply will not be compliant due to the involved nature of multi-layer bandaging. There are foam sleeves for arms & legs that can be used with bandaging to reduce the steps. There are some foam options that have compression in them. Velcro may be a good option for night compression as well as straps are adjustable.
Unfortunately, many times patients do not have sufficient help to don or doff garments. And, due to arthritis or other reasons, they may not have enough strength to put certain types of compression on. Hose can be difficult to get on an arm or leg. Challenges of strength, mobility & bilateral arm use can be just some of the barriers. There are several donning & doffing aids available which we will mention in future blogs. However, Velcro may be a suitable alternative & more cost effective when compression is needed at night, also.
In summary, aside from contraindications (such as impaired arterial blood flow or latex allergy), numerous considerations need to be considered when choosing the right compression. In our next blog, we’ll begin introducing the well-known manufacturers & some of their best selections for lymphedema.
1Foldi, M, Foldi, E. (2006). Foldi’s Textbook of Lymphology (2nd ed.), p. 574. Germany: Urban & Fisher. Foldi, M, Foldi, E. (2006).