Lymphovenous Canada: A compression garment fitter shares her experiences

I started working for House of Kraft Orthopedics in 1977 and became a fitter of corsets, mastectomy prosthesis and compression garments.

At that time compression garments usually meant lower limb stockings for the people who could walk in off the street with a prescription in hand. Rarely, once every two or three years, would we see somebody with a prescription for a compression garment to control lymphedema in an arm.

I learned to be a fitter through many years of experience. I frequently take courses run by suppliers on how to fit their garments to keep up with what comes out.

It was so different when you worked for a company and people were walking in off the street. Now that I work for myself I see people who are really sick who are going through treatments and who have a hard time going places. That's why I started the in-home service. These days I see both children and adults who need custom garments because they have severe lymphedema.

I concentrate on providing compression garments and orthopedic shoes. Orthopedic shoes and compression stockings seem to go hand-in-hand. People who have edema in their feet often have problems with footwear. So I have some special footwear I use if people need it.

I am registered with social services and I also accept clients who pay through private insurance coverage. I work with a lot of different agencies such as the Breast Cancer Action Ottawa, manual lymph drainage specialists, as well as medical centres in the area such as the Otttawa hospitals.

My philosophy is that I will use any company's products - so long as it works for my client, that's what we go with. Some have great cotton garments, some have stretchy garments and some have really heavy-duty garments which are particularly good for lymphedema. Brands that I use are: Venosan, Juzo, Sigvaris and Jobst.

Right now I am working with the Victorian Order of Nurses (VON) on a leg-ulcer program. The patient has a leg ulcer, the nurse cleans it up, wraps it in profor dressings, and when it is cleared up, I am called in to get them into compression garments.

I think a main problem with everybody, is putting the garments on. With upper extremities you have one hand to use. Sometimes you have a patient with severe lymphedema who would be ideal to go into a high pressure garment, but they can't put it on themselves. So we may have to go with a garment that has a little lower compression. Or they can't tolerate it so we can't go as high as we might want to go with the compression.

With upper extremity a difficult fit is where the hand and the arm is involved because there is an overlap of compression garments. In these cases we sometimes have to go for a custom-made garment. People who use a one-unit garment sometimes find the area where the hand and thumb meet creates a pressure point, which is quite painful. When we fit, we try to go for two pieces first. Juzo has a great hand piece and great sleeves which go right up and over the shoulder. With that combination it usually works quite well. Sometimes where the two overlap we have a bit of a problem. If it is really bad we get a custom-made one-piece. Where the woman has a two-piece however they can take the hand piece off and wash their hands and that makes a big difference.

Juzo has a custom-made compression vest garment for people who have lymphedema across the chest and breast area. You can get class one and two compression but because you are wearing it constantly across the torso it can be more than what some people can tolerate. That costs around $500.

They also have an Expert line compression bra that looks like a sports bra, for about $160 which has two layers against the skin. The patient can control the fit with a Velcro closure at the back and then the second layer comes from the front that you can wrap around you like a tensor bandage to the area where lymph tends to pool. You can add another layer of foam - that also helps. The only problem with that bra is that you almost need someone to help you get it on. The most common garment I use is a Camp mastectomy bra which costs about $60.00 which can control lymphedema across the chest if it fits well.

Elvarex is a new compression material which has just been introduced in Canada. The Assistive Devices Program in Ontario doesn't cover it right now for upper extremities, but it does cover it for lower extremities. It is very heavy but it is flexible in the styles you choose. It is ideal for someone who is younger and has the strength in their hands so they can don it.

If a man has genital lymphedema, he has to get that fluid out with manual lymph drainage first before fitting with a garment. I have seen a couple of men with genital lymphedema and we have made a sling with a cotton stocking by wrapping it around their waist so it doesn't hang too much. And that works. It's like using a bra for a compression garment - that would be the closest example. We did try compression hose for a man who had genital lymphedema and he couldn't tolerate the pressure because he had had no manual lymph drainage so we had to go really low.

People who have difficulty pulling garments off and on should be using rubber gloves. It makes a big, big difference. If they still can't do it, I will try a lower pressure of compression than prescribed and confirmed with the physician, such as a class one which is much easier to don because it stretches a little better.

It is really difficult when a person is overweight and they can't touch their toes. There are a lot of slip and slide types of equipment available but they really don't work if you can't touch your toes. In a couple of these situations homecare have made arrangements to come in. In one case they go in for 15 minutes twice a day - once to put the garment on and once to take it off. With another individual a worker comes in twice a week to change the garment which this individual wears 24 hours a day. We had to go a little lower in compression so he could tolerate it. And every three days he has it removed, he has a shower and before they leave they put it on again. This is so that the ulcers don't come back. These two people really are in quite a predicament - they have to wear it or else they develop serious skin problems.

In most cases we don't fit garments on individuals until their wounds have healed. With a couple of people at the tail end of their treatment, where their ulcers are dime-sized we have put compression garments over top of the dressing which are very thin. But nurses are still involved and won't discharge the individuals until the wound has healed.

I'm not a great fan of zippers. The few times I have had garments made for clients with zippers they tend to ripple on the leg. You can really see the groove on the leg because you have two or three layers at the point it comes together and then there is the fold the zipper slides on. Whether you have a zipper or no zipper you still have to fit the garment really snugly. You still need two hands to pull that material together and then you have to pull up the zipper.

But sometimes there are cases where you can't use stockings without a zipper. I have a lady whose hip is fused. In her case she could reach down but couldn't bend her legs to put on the stocking. So for her the zipper worked quite well.

In fitting sleeves, people usually go to a manual lymph drainage specialist to get the swelling down. When it is down they are then fitted for a sleeve. We try to move as much lymph fluid out of a limb before fitting a garment and in rare cases where this is not possible we would still fit a garment on an arm for support and comfort. The sleeve doesn't usually bring the swelling down on its own - it has to be done with manual lymph drainage to do that.

Regarding people who have difficulty with synthetic garments - you have to make sure the individual is not latex sensitive. Most of the garments now have synthetic material which doesn't usually create problems with the skin, unlike the older garments which had rubber in them. Sometimes we do have a problem and in those situations we usually use a cotton liner.

Some of the knitted materials, such as Elvarex, tend to breathe easier in the heat even though they may be heavier. The only drawback with this custom-made garment because of the rubber content it may not always fit the same - but most people seem to be really happy with it.

Regarding colour - many ladies get the flesh-tone garment and then wear a stocking over top of it and it doesn't seem to be a problem. If you have a wedding you have to go to and you can't be without a compression stocking my advice would be: wear a lower class of stocking with a nice colour and go and enjoy the day. Then the next few days after the evening your legs might be a bit swollen and you might have to do a bit of manual lymph drainage or self-massage to get it down - but it usually goes down and you enjoy the day.

Good measurements are important, especially length of the stockings. Too long and stockings will bunch up and create discomfort. I also find measurements are a guideline to where I begin, but fitting and trying the garment would be the real test.

Final words:

If someone has a brand of stocking that works, my advice would be don't change it! When you go to someone who provides you with a garment you should be looking for something that fits well. It may not be wonderful but it shouldn't be painful. If you have a garment that you feel doesn't fit and a fitter says it does, go and see someone else for a second opinion. You are the one who has to wear it so you know if it is working for you.