Lymphedema patients come in all shapes and sizes and have wide-ranging needs that must be considered when prescribing compression garments. Quite often, therapists face the challenge of encouraging their patients to be compliant in wearing compression long-term, as some people refuse to wear them if they are uncomfortable or ill-fitting. This long-term commitment to wearing garments is one of the major keys to successfully managing Lymphedema swelling, so it is essential that therapists and patients understand the technical aspects of how garments are constructed and the science behind how they work.
Once a patient has undergone a full assessment; the best type of hosiery should be chosen that aligns with the extent of their swelling, therapy needs, their comfort and physical ability to apply and take off the garment. Lymphedema patients have a choice between ready-made garments and custom-made garments, each of which has certain points that need to be considered before committing to.
Ready-made garments come in a variety of lengths, fabrics and compression classes and are fabricated based on ‘average’ limb proportions. This means that sizes are predefined and are less adaptable to an individual patient’s size and limb shape. They are made with thinner fabrics than custom-made garments and are seen as more ‘cosmetically appealing’ to the eye. In terms of support, they may not provide enough containment for advanced cases of Lymphedema and can cut into skin folds and tourniquet. They are well suited to patients with venous disorders and people with mild Lymphedema where there is little shape distortion.
Custom-made garments are made with thicker (but breathable) materials and can be produced in almost unlimited shapes, sizes and all four compression classes. This makes them a better anatomical fit for Lymphedema patients, who often have some degree of shape distortion in their limbs. The thicker materials provide stiffness and a higher containment of edema, which also makes them less prone to curling, twisting or cutting into skin folds. They also have the advantage of giving different levels of compression at different areas within the same garment.
One important factor to know about each type of garment is the way they are constructed- as this greatly affects the way each garment performs and the level of compression it applies on the skin. The fabric in ready-made garments is knitted with a circular stitch and gives a tube appearance to the garment. They suit a smaller range of shapes and sizes, have a higher degree of stretch and exert less pressure on the tissues compared to flat-stitch garments. Flat-stitch is the type of knitting used in custom-made garments, which produces a flat garment that has been knitted row-by-row. The material in flat knit compression stockings is relatively low-stretch and has a high working pressure, which means they exert a high pressure on the tissues. It should be noted that a wide range of ready-made, flat knit compression garments do exist but their capability of suiting a wide range of complex anatomical needs to be looked at further.
As explained by Wounds International (2009), “People with complex lower limb and torso lymphedema will often require custom-made garments. Custom garments are most often made using flat-knit technology since it can accommodate a wide range of anatomical distortion, when different levels of pressure are required within the same garment at different sites, or when special adaptations are required.” In saying this, recent clinical experience has shown that ready-made circular knit garments have been effective in treating mild cases of Lymphedema.
What do I need to know before choosing a type of garment?
There are many factors that need to be taken into consideration before deciding upon a pair of custom-made or ready-made garments.
This depends on the person’s grade of Lymphedema- mild to moderate cases can adapt to either custom made or ready-made garments as they are available in all four compression levels. For more severe cases of Lymphedema, higher compression levels may be required which means custom-made garments are needed.
Putting on compression garments (or “donning”) is a workout by itself, even for the youngest of patients! So for patients who are elderly, disabled, obese or have arthritis, it can be extra challenging when a class four compression stocking is involved. Strength and physical capability to don garments need to be evaluated and catered to accordingly for each patient. For example, layering two lower grade garments can make it easier to don for patients with reduced strength abilities. Zips can also be added to garments if needed.
Presence of wounds and skin conditions
If open wounds or other skin conditions are present, a patient may require compression that lets the air come more easily in contact with the skin or a soft material (like cotton) that does not irritate sensitive skin.
Size and shape of the affected area
One issue with ready-made garments is that they are produced in a limited array of sizes and are often tailored to ‘average’ limb proportions. Often these sizes don’t match our limbs and instead, we require a custom-made garment. Although some ready-made garments do accommodate extra-wide areas (such as elbows and calves), the rest of the garment might be out of proportion and cause additional problems, like swelling in areas that are not as compressed. In the case of very obese patients, custom-made is generally the only suitable solution.
It’s important that people feel comfortable in their compression garments in order to have any kind of long-term success in wearing them consistently. Therefore, it’s important to discuss with your therapist what are your concerns and preferences. Aesthetically speaking, if you are not happy with how your garment looks (whether it’s an annoying zip, colour issues, scratchy materials or a seam that you don’t like), make sure your therapist knows about it and can match you with a more suitable garment.
When to order a new compression garment
The general guideline on compression garment usage is that you should replace them every 4-6 months. The lifespan of a compression stocking depends on various things, like how often you wear them, your level of physical activity whilst wearing them and how well you take care of them (eg: washing with proper products, not putting them in the dryer!). Even the best compression garment will wear out over this time period and loose its compression effectiveness. In many cases, when patients have a reduction in size, a new stocking may be required sooner than the recommended timeframe because the original one becomes too big.
A good tip to help you increase the life of your compression garments is to purchase a few pairs and rotate them during the weeks. Although this requires a bigger financial investment at the beginning, garments will last longer than usual and the need to replace them will be extended, hence saving money in the long run! Also, another great idea is to buy a range of garments to wear in different situations- for example, a specific pair that you use for sport, one for everyday general wear and one for relaxing around the house.
Lymphoedema Framework. Template for Practice: compression hosiery in lymphoedema. London: MEP Ltd, 2006.
Wounds International (2009), Template for practice: Compression hosiery in lymphoedema.