Many people with Lymphedema unintentionally make the mistake of thinking that their day-time compression garments are suitable for sleeping in but the truth is, that sleeping in day hosiery could actually be doing you more harm than good. “Daytime garments, such as elastic compression sleeves, are not appropriate to wear at night. The compression is too high and they are prone to slipping, binding and creating a harmful tourniquet effect,” explains Patricia Montagano, a Registered Nurse and Advanced Garment Fitter.
A major effect of compression therapy for lymphedema patients is to help reduce the formation of excess interstitial fluid in areas of the body where the lymphatic system is no longer functioning properly. Compression garments come in an array of different designs, materials and pressure levels, all of which are carefully combined to produce a garment that suits a particular purpose- like standing all day and being active or laying down sleeping at night. It’s important to understand the technology that goes into making these garments and in what situations they work best, to ensure that we get the best performance out of them- whether we wear them during the day or night!
Factors which influence the application of compression garments
The technology that goes into designing compression hosiery is impressive but rarely a talking point when we go and get measured by our garment fitters. All we know is that we ‘need to wear compression’, full stop! So it’s no wonder a lot of us think our day garments are okay to wear at night! There are many factors which influence the effectiveness of compression garments that ultimately determine their application, making them either suitable for day-use or night-use (and not both).
We’ve outlined below a few important points below that explain why it’s important to wear only specialised night garments for sleeping in, or day garments exclusively for active day-wear. You’ll see how they both work differently to achieve the same purpose- reducing and containing oedema- and why it could be harmful to wear garments in situations in which they are not intended for.
High pressure VS lower pressure
All compression garments are designed to counteract capillary filtration pressure, which is the force that drives fluid in and out of capillaries. When we are standing, filtration pressure in the leg is higher than when we are laying down. This means that day hosiery needs to exert a higher pressure than nightwear, providing optimal pressure when in the upright position, to help reduce the formation of excess interstitial fluid in surrounding tissues (Lymphedema Framework 2006). Night garments also oppose fluid filtration into tissue but do this using a lower level of compression. Capillary filtration pressure is lower when laying down and less pressure is required to prevent fluid from entering tissues.
Stiff materials VS softer materials
If you’ve ever used a night garment, you will know that they feel really different to day-hosiery. Night garments use foam and breathable, lightweight materials that micro-massage the skin and stimulate lymphatic drainage. The foam components help to create both high and low-pressure points in the subcutaneous tissues that help to increase venous reabsorption, improve lymphatic drainage and move excess proteins out of the area (Jovipak, 2016). They are also designed with specially textured grooves that direct lymph flow back towards the heart.
Daytime garments, on the other hand, are constructed with more resistant materials, such as yarn, which give them a stiffer, coarser texture than night garments. This composition influences their pressure profile and creates garments with higher compression levels, which is simply too high for night-time use.
Gravity, muscle pumps and other external pressures that are absent at night
Lymph movement is partially propelled by external factors, such as muscular contractions or MLD, which exert an external pressure on the lymphatic walls and help increase particle uptake. When we increase our physical activity, we help lymph to flow faster. But in cases of Lymphedema, when the lymphatic system isn’t working properly, this ‘flow’ doesn’t happen naturally and need to be stimulated by a carefully measured amount of external pressure that works in sync with muscle contractions to move the lymph. Pressure levels in day-garments are designed to increase when we stand up and fluctuate during walking- which is an important feature that helps increase lymph absorption (Lymphedema Framework 2006).
Night garments, on the other hand, are simply not required to do undertake any of these actions. When sleeping, we don’t have the forces of gravity pushing liquids down into our legs, muscle pumps to counteract, or increased internal pressure when we are standing or walking. Night-garments, therefore, don’t require the same stiffness or compression levels to move lymph. Their strength lies in the use of foam sewn into channels that exerts high and low pressures in the tissue, which directs lymph fluid laterally and proximally and out of the affected area.
What compression should I be wearing at night, if any?
The benefits of continuing compression over a 24 hour period have only recently come under the spotlight, with some stunning findings being discovered in patient studies. One of these studies (Whitaker, J. 2016) found that an increase in Lymphedema swelling was documented in 89% of all patients when night-time compression was not used¹. The study concluded that patients who wore compression at night were able to successfully avoid rebound oedema and reduce interstitial fluid in the affected regions.
The majority of Lymphedema patients can benefit from practising compression at night to help reduce swelling and fluctuating oedema while they sleep (see contraindications here). Currently, there are two choices for Lymphedema night-time management: traditional bandaging (wrapping) or night-garments.
Traditional bandaging consists of wrapping the limb with multiple layers of short-stretch (inelastic) bandages, such as Comprilan, foam and/or cotton layers, that provide the kind of permanent, working pressure needed to stimulate lymphatic drainage, even when you are resting². Wrapping is a great way to help reduce volume and move excess fluids out of the tissues. The downside of wrapping is that some people struggle to sleep comfortably with bandages on and can often end up taking them off during the night, with the main reasons being that people get too hot with them on, they apply the bandages too tightly (which can obstruct lymphatic flow) or have an allergic reaction to the materials.
Night garments offer an alternative to bandaging, which can be extremely welcome for those who have given up on night-time management due to the difficulty of keeping their limbs wrapped all night! The design of night garments in recent times has become better and there is a range of products that exist on the market that suit a wide variety of shapes, sizes and budgets. Custom-made night garments will give you a better anatomical fit and the right compression gradient for your specific needs, however, they are generally more expensive to buy. Ready-made garments are less expensive, which is great for those who are budget conscious, but they may not provide the exact support your limbs require, making them work less efficiently.
There is no right or wrong answer when it comes to choosing the best type of night compression for yourself. Everyone is different and what one person can tolerate, another may not. Certain factors need to be considered when choosing a type of night compression, to make sure they are comfortable and give the correct level of compression for your individual needs. Consulting with a fully trained garment fitter is essential for finding the right solution. Factors that should be considered when choosing a night garment include:
1: Whitaker, J (2016): ‘Lymphoedema Management at Night: views from patients across five countries’, British Journal of Community Nursing, 21 (Sup10) pp. S22-S30
2: Lymphedema Products: http://www.lymphedemaproducts.com/products/short-stretch-bandages.html
Montagano, P. 2011: Night Time Garments. Guidelines and Resources. email@example.com
Lymphoedema Framework. Template for Practice: compression hosiery in lymphoedema. London: MEP Ltd, 2006.
Shayan, Ramin; Achen, Marc G.; Stacker, Steven A. (2006). “Lymphatic vessels in cancer metastasis: bridging the gaps”. Carcinogenesis. 27 (9): 1729-38. PMID 16597644. doi:10.1093/carcin/bgl031.