Chapter 27: Living with and beyond cancer
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Compression garments
Definition
Elastic compression garments are used in the long‐term management of lymphoedema. Patients are required to wear their garments daily, with most patients wearing their garments all day and removing them at night. For some patients, their treatment plan may include the flexibility to wear the garment just for exertive activities or for a few hours each day, depending upon their needs.
Evidence‐based approaches
Rationale
Choosing the correct garment for the patient can be a difficult decision and should always follow a detailed assessment of the patient (Todd [273]). It should only be undertaken by a healthcare professional with knowledge and appropriate skills to ensure patient safety.
The size of the required garment can be determined by following the manufacturer's individual size chart and recording three or four circumferential measurements at set points along the length of the limb. It is important to remember that size charts provide a guide only, and the patient's evaluation of the comfort of the fitted garment is essential. An alternative style or a larger or smaller size may be required.
Indications
Contraindications
- Arterial disease. Blood supply may be further compromised (Elwell [99]).
- Acute heart failure. Symptoms may be exacerbated (Elwell [99]).
- Distortion of limb shape. The garment will not fit (Todd [272]).
- Skin folds. The garment will cause ridges and a tourniquet effect to the limb (Todd [272]).
- Open wounds. The garment will become soiled and pose an infection risk.
- Fragile skin. Application and removal of the garment may cause further damage to the skin (Todd [272]).
- Lymphorrhoea. The garment will become wet and may cause skin excoriation (Todd [272]).
- An acute infective episode (cellulitis). Application and removal of the garment may be painful and cause damage to the friable skin (Elwell [99]).
- Severe peripheral neuropathy. The patient will not be able to tell if the garment is causing damage to the skin (Elwell [99]).
Legal and professional issues
Ensure the patient understands how to use compression garments and has given consent (NMC [202]).
Pre‐procedural considerations
Several factors need to be taken into consideration before deciding to fit a patient with an elastic compression garment. The patient should be motivated and compliant with the use of garments and have the physical skills to apply and remove the garment safely. A full physical assessment of the patient will determine the condition of the skin and tissues and the shape and size of the limb in order to determine the style, size and appropriate compression class of garment suitable for the patient.
Equipment
A wide range of elastic compression garments for the treatment of lymphoedema is now available on the drug tariff, making it easier for patients to establish a long‐term supply of their garments.
Elastic compression garments apply an external force to the limb which pulls in to exert pressure on the tissues below (Partsch [221]). The pressure can be sustained over long periods of time during both activity and inactivity of the limb, providing a high working pressure while the muscle is active and a high resting pressure during inactivity of the muscle at rest (Elwell [98]).
It is important to acknowledge that different classifications of compression exist. These are determined by testing methods, yarn specification, compression gradient and garment durability (Elwell [99]). In the UK, elastic compression garments are available in the British Standard BS 6612, French Standard ASQUAL and German Standard RAL‐GZ 387:2000. Each standard adopts different testing techniques to determine the degree of pressure measured at the ankle when the garment is in place, and the pressure range used to define the compression class of the garment differs between each of these standards (Partsch [221], Todd [273]). The compression levels used are generally higher than those used to treat venous disease and are classified according to the range of pressure exerted at the ankle by the garment. Table 27.17 outlines the indications for compression garments and the suggested compression classification. Although the differing standards may appear confusing, it is useful to be able to select garments from a range of manufacturers to find the most suitable garment and to allow patients a wider choice.
Table 27.17 Compression classes and indications for their use
| Indications | Suggested compression level |
|---|---|
| Mild lymphoedema | Class 1 |
| Low compression
British Standard: 14–21 mmHg
French Standard: 10–15 mmHg
German Standard: 18–21 mmHg |
| Moderate lymphoedema | Class 2 |
| Medium compression
British Standard: 18–24 mmHg
French Standard: 15–20 mmHg
German Standard: 22–32 mmHg |
| Severe lymphoedema | Class 3 |
| High compression
British Standard: 25–35 mmHg
French Standard: 22–32 mmHg
German Standard: 34–46 mmHg |
The use of elastic compression garments (Partsch and Mortimer [220]):
- increases interstitial tissue pressure and reduces production of lymph
- promotes lymph movement along superficial and deep lymphatics
- increases lymph reabsorption
- provides an external counterforce during activity which enhances muscle pump action.
A wide range of garments are available which differ in construction, compression class and style, in addition to size and colour.
- Construction. Garments are manufactured as either round‐knit or flat‐knit. Round‐knit garments are produced in one piece from synthetic fibres and are readily available in a variety of sizes ‘off the shelf’ to accommodate the needs of most patients. Although more cosmetically acceptable to patients, these garments tend to roll or gather in areas along the limb if the limb is mis‐shapen (Todd [272]). They are more suitable therefore for patients whose limbs have maintained a regular shape. Some round‐knit garments are manufactured with inelastic materials, creating a stiffer garment. The pressure under these garments will be higher while the muscle is active. Flat‐knit garments are manufactured from one piece of material sewn together with a seam. The shape can be adjusted during manufacture to suit patients’ specific needs and the provision of accurate measurements before manufacture ensures a good fit. Flat‐knit garments offer the highest working pressure relative to their resting pressure and are more suitable for patients with moderate to severe lymphoedema (Todd [273]).
- Compression class. The degree of pressure exerted by the garment on the surface of the skin it surrounds determines its compression class (Todd [273]). The highest compression provided by a garment when fitted can be found at the wrist or the ankle. The compression is then graduated along the length of the limb to encourage movement of the fluid out of the limb.
- Style. All areas affected by swelling must be contained within the compression garment or further swelling will develop. The patient should be instructed concerning the application, removal and care of the garment to ensure that maximum effectiveness is achieved through its use. The patient's physical ability must be taken into account when choosing a garment as a high degree of dexterity and strength may be required during its application and removal and this may be impractical for the patient (Todd [273]).
- Size. The correct garment is one that fits well and is comfortable for the patient with no loose pockets of material where swelling can develop and no areas of constriction where a tourniquet effect can occur. The manufacturer's guidance for choosing the correct size is based on simple limb measurements and particular attention should be given to the fit at the ankle or wrist where high levels of compression can occur (Todd [273]).
The application of elastic garments can be greatly eased by the wearing of household rubber gloves during application; gloves facilitate control of the garment and prevent damage to its fabric. Application aids are also available commercially and may assist some patients who experience difficulties (see Table 27.10). Moisturizing cream should be applied at night‐time rather than in the morning before putting the garment on. A very fine layer of talcum powder applied to hot sticky skin can ease application. If this is the first time that the patient has worn elastic compression garments, the therapist should explain to the patient that the feeling of pressure may seem strange for the first few hours, but that it should not cause pain in the limb or numbness in the digits or toes.
Procedure guideline 27.14
Elastic compression garments: application to the leg
Procedure guideline 27.15
Elastic compression garments: application to the arm
| Problem | Cause | Prevention | Action |
|---|---|---|---|
| Wrinkling of the garment along the length of the limb. | Poor application and positioning of the garment. | Supply written instructions with diagrams/pictures concerning the application and removal of the garment. | Demonstrate application and removal of the garment and observe the patient's technique when the garment is provided. The use of donning aids may be required. |
| Slippage of garment during wear. | Poorly fitting garment. | Ensure the correct measurements are taken to guide the therapist in the selection of the correctly sized garment. | Review size of garment. Consider the use of a grip top or skin glue to minimize slippage at the top of the garment. |
| Change of sensation in the limb during wear of the garment. | Garment too tight. | Ensure the correct measurements are taken to guide the therapist in the selection of the correctly sized garment. | Assess for other possible reasons for a change in sensation, e.g. musculoskeletal or circulatory impairment.
Review the size of garment and consider alternative garments. |
| Skin sensitivity or reaction when wearing compression garment. | Possible allergic reaction to the material of the garment. | Check the patient's allergy status prior to fitting a garment. | Treat any allergy appropriately. Remove the garment until skin reaction clears. A cotton stockinette lining can be worn underneath the garment to protect the skin. An alternative garment may be required. |
| Poor compliance with use of the garment. | Limited information given to patient with regard to the importance of wearing the garment. Lifestyle commitments. | Ensure the patient is given sufficient information to become compliant with treatment. | Explore the problems the patient is experiencing. Explain the purpose of the garments thoroughly and the intended benefits. |
| Swelling extending beyond the edge of the garment: fingers or toes, upper thigh or upper arm. | Inappropriate style of garment for the patient's needs. | Thorough assessment to establish the history and extent of swelling. | If fingers or toes are swollen, use a compression glove or toe caps. If upper thigh or upper arm is swollen, the garment must extend into the adjacent truncal quadrant. |
Figure 27.20 Example of elastic compression garment for the leg.
Figure 27.21 Example of elastic compression garment for the arm.
Post‐procedural considerations
Immediate care
Evaluate the overall fit of the garment. There should be an even pressure throughout the garment, with no areas of loose‐fitting material. The garment should be comfortable so that the patient can use their limb without restriction.
Ongoing care
The shape and size of the limb may change due to an increase in swelling. This can cause the garment to become ill fitting and cause trauma or damage to the skin. Compression garments should be checked regularly to ensure they remain appropriate in size, style and fit.
Education of patient and relevant others
- Ensure the patient knows for how long the garment needs to be worn each day. As each patient is different, the therapist should advise appropriately. Ideally garments should be worn during waking hours and removed at night (Todd [273]).
- Advise the patient on the care of the garment. The garment should be washed after every wear at 40°C. Hand washing is also acceptable. A biological detergent can be used but fabric softener should be avoided. The garment should be air dried and not tumble dried.
- Advise the patient about how to acquire replacement or additional garments. Many garments are available on drug tariff from the patient's doctor. It is advisable to replace the garments every 6 months.
