Journal of Tissue Viability 1999 Vol 9 No 3 89

'Putting the pressure on': a study of compression sleeves used in breast cancer-related lymphoedema

Anne F Williams 1 and Angela E Williams2

1Senior Lecturer/Nurse Researcher, Centre for Research and Implementation of Clinical Practice, Thames Valley University, Wolfson Institute of Health Sciences, London 2New Opportunities Manager, Optimal Healthcare Solutions Limited, London

Breast cancer-related lymphoedema is a chronic, progressive condition characterized by swelling in the arm and adjacent trunk, with changes to the skin and underlying tissues. The application of compression garments is an essential component in the long-term management of lymphoedema. A wide range of garments is available in the UK; however, there is limited literature to guide therapists in their appropriate selection. This paper reviews the effects of compression therapy, outlines the components of lymphoedema treatment, and discusses features of lymphoedema compression sleeves. A small study of nine women with breast cancer-related lymphoedema is reported. The study investigates the interface pressure profiles of a selection of commonly used compression sleeves as measured by the Oxford Pressure Monitor. The results showed a wide variation in the interface pressures for all sleeves. A graduated profile along the length of the arm was not always present. Two layers of garments led to markedly increased pressures at the top of the arm but the pressures along the arm did not double. The possible implications for clinical practice are discussed.

Introduction Breast cancer-related lymphoedema is a chronic, progres­sive condition characterized by swelling in the arm and adja­cent trunk with changes to the skin and underlying tissues (Figure 1). A prevalence study in one health district identi­fied lymphoedema in 28% of women treated for breast cancer1. Lymphoedema results in reduced mobility and function, impaired quality of life and psychological dis­tress2. Although it is not curable, lymphoedema can be successfully controlled with appropriate treatment. The application of compression garments is an essential compo­nent in the long-term management of the swelling3A.

There is a wide range of compression garments (hosiery) available in the UK. Research into this area of practice is limited, however, and a search of the MEDLINE database (1966 to date) and the Progress in Lymphology abstract books (1985 to date) indicated that there is minimal litera­ture to guide therapists in selecting and fitting compression garments for lymphoedema. There are a number of studies into compression therapy in venous disorders although it is not clear how relevant the findings are to lymphoedema.

Received 4 February 1999; revised 26 March 1999; accepted 12 Apri/1999

This paper reviews the effects of compression therapy, outlines the components of lymphoedema treatment and discusses features of compression sleeves used in lymphoedema management. A small study of the interface pressure profiles of 14 combinations of single- and double­layer compression sleeves used in the treatment of lymphoedema is reported. Clinical implications of the find­ings are discussed and recommendations for further research priorities are made.

Physiological effects of compression therapy The majority of studies into compression therapy focus on venous disorders of the leg. These highlight a number of effects: an improvement in the calf muscle pump, increased venous return and reduced venous volume5'6, a reduction in venous hypertension7, improved lymphatic flow and reduced lymphatic hypertension8. Other changes such as improved micro-circulation9 and reduced lipodermato­sclerosis10 have also been reported.

As already noted, there have been very few studies of the effect of compression garments on a lymphoedematous

© Tissue Viability Society

90 Journal of Tissue Viability 1999 Vol 9 No 3

Figure 1 Breast cancer-related lymphoedema

limb. The literature suggests that compression therapy improves lymphatic flow by increasing tissue pressure 11

and providing a counter-force to muscle contractions, so improving the muscle pump3. A physiological study of interstitial fluid pressure using the wick-in-needle technique reported that hosiery also counteracts capillary filtration and promotes drainage along connective tissue planes12.

Lymphoedema treatment The physical treatment of lymphoedema comprises two phases: intensive and maintenance13. An intensive treatment regimen incorporates daily multi-layer bandaging, manual lymphatic drainage and/or self-administered massage, exer­cise and skin care, aiming to reduce limb volume and improve shape over a period of several weeks. During the maintenance phase, the patient undertakes a daily routine of self-help treatments including skin care, exercises, self­administered massage and application of elastic compres­sion hosiery14. It is crucial that such garments are effective and acceptable to the wearer in order to maximize the effect of the treatment, as clinical experience suggests that fluid is likely to re-accumulate spontaneously if hosiery is not worn. The aims of compression hosiery in lymphoedema are to:

(1) encourage the fluid to move to the root of the limb (2) limit the re-accumulation of oedema (3) maximize the muscle pump (4) support the tissues to enhance comfort (5) maintain shape (6) improve skin condition

Lymphoedema garments A variety of standard, 'off-the-shelf' garments are available in the UK for arm lymphoedema. These include sleeves with or without handpieces and a number of other features such as shoulder caps, bra strap attachments and elbow shaping. Separate handpieces and gloves are also available.

Garments are constructed using a circular or flat-knit design. The majority of standard garments available in the UK are circular-knitted on computerized machines, with continuous spiralling threads. Most of these are made of Lycra® (DuPont) and polyamide (a type of nylon), although natural rubber is sometimes used instead of Lycra. Lycra is a thin thread which, used within a circular-knit design, provides substantial widthways and lengthways stretch. It maintains its compressive properties with regular washing and 'rest­ing', so patients require a minimum of two garments. Lycra­based sleeves are mostly smooth and highly elastic and conform to the shape of the limb. Some have an elastic inlaid thread that helps to maintain compression and dur­ability. Other garments, for example those knitted with thicker threads such as natural rubber, are more rigid and conform less readily to limb shape. This may be advant~ ageous for patients with a poorly shaped limb.

A small range of flat-knit garments which incorporate elbow shaping and a side seam are provided 'off-the-shelf' in the UK. These were not available at the time of this study and therefore have not been included. It is interesting to note that clinics in a number of other European countries routinely use flat-knit, made-to-measure garments rather than the circular-knit, Lycra-based sleeves. These are often a thicker, more rigid style of garment which have the additional benefit of being knitted to fit individual anatomical shapes. All hosiery companies in the UK provide a made-to­measure service for various garment styles.

Levels of compression Manufacturers of the sleeves used in the study indicate the range of expected wrist pressures provided by their selection of garments using the continental 'Hosy' system. However, the expected graduated profile has only been illustrated with reference to lower limbs (as in Figure 2). Furthermore, it is generally assumed that a graduated pressure is required for lymphoedema; however, the nature of this graduation has not been discussed in the literature nor subjected to study.

Sleeves of compression classes 1 (18-21 mmHg) and 2 (25-32 mmHg) are the most commonly used in lymphoedema. Occasionally, sleeves of compression class 3

Maximum 40%

Maximum 50%

Maximum 70%

Maximum 100%

Figure 2 Compression profile of a stocking

(36--46 mmHg) are applied, for example following an inten­sive treatment programme. A combination of factors affect the elastic tensile strength of a garment to provide different levels of compression; various knitting techniques and fibres are used, the numbers of rows and stitches are varied and threads are pulled to different tensions as they leave the spool.

Study design and method The study aimed to record the interface pressure profiles, as measured between the skin and compression garment by the Oxford Pressure Monitor, in a selection of commonly used sleeves. A convenience sample of nine women with breast cancer-related lymphoedema registered -with the Lymphoedema Service at Sir Michael Sobell House, Oxford, UK, were recruited. Their median age was 66 years (range 54-80). In each case there was no evidence of active disease and they were all in the maintenance phase of treat­ment. The study was described to each subject and consent was obtained.

The Oxford Pressure Monitor is a microprocessor­controlled unit which can continuously monitor and record interface pressure in mmHg. The small, sealed air sacs inflate until the internal pressure matches the external

Journal of Tissue Viability 1999 Vol 9 No 3 91

pressure acting across it. It is limited to recording static pressure measurements, or slow pressure change, and there­fore, for the purpose of this study, resting pressures were tested. The monitor gives repeatable results and an accuracy of3% 15.

Limb volumes were calculated by incorporating circumferen­tial limb measurements into the formula for a cylinder, and excess volume was expressed as a percentage of the unaf­fected arm16. In this group of patients, excess limb volume ranged from 20 to 64% (median 46% ). The study sleeves were selected for individual patients according to the manu­facturers' instructions. All were new sleeves and were applied in 14 combinations of single and double layers (Table 1).

The researchers worked together with the first two patients, to ensure consistency of the method, then individually for the remaining seven patients. Four pressure cells of the Oxford Pressure Monitor were taped onto the skin at pre­determined sites along the arm (Figure 3): wrist (position 1), 5 em below epicondyle (position 2), 5 em above epicondyle (position 3) and the top of the upper, outer arm (position 4) before the sleeves were applied. The arm was supported in a resting position on a pillow before the pressure measure­ments were taken. Pressure values in mmHg were recorded in all nine patients at the four positions on the arm, for all sleeve combinations. Two measurements were taken at each position and the mean of these was calculated.

Results were printed out and transferred to Microsoft Excel spreadsheets for descriptive statistical analysis. The median and range of pressure for the four positions and the percent­age of wrist pressure at the top of the arm are reported (Table 2).

Study results

Interface pressures The median and range of wrist pressures for single-layer sleeves corresponded with the compression class values

Figure 3 Position of the four pressure cells along the arm

92 Journal of Tissue Viability 1999 Vol 9 No 3

described by the manufacturers for individual sleeves in almost all cases. In some cases, the range of pressure was considerably wider than expected but this occurred across the sample in all sleeves and for all positions.

The application of a second layer of hosiery increased median wrist pressure. However, this increase was not equivalent to doubling the compression value. For example, a 710 worn with a 504 gave a median wrist pressure of 39 mmHg with a range of 21-49 mmHg as opposed to potential pressures of 53-67 mmHg.

Pressure profiles The pressure profiles, as recorded in sequence by the four cells, varied between patients. A sequential reduction in

Table 1 Details of the sleeves used in the study

Sleeves and combinations

Single layer

Medi 710 Lycra (elasthan) +polyamide

Medi 712 Lycra (elasthan) +polyamide

Sigvaris 902 Lycra (elasthan) +polyamide

Sigvaris 503 Rubber (elastodiene) +polyamide

Sigvaris 504 Rubber (elastodiene) +polyamide

Double layer

Medi 710 + Medi 710 Medi 710 + Medi 712 Medi 710 + Sigvaris 503 Medi 712 + Medi 712 Medi 712 + Sigvaris 503 Sigvaris 902 + Sigvaris 503 Medi 710 + Sigvaris 504 Medi 712 + Sigvaris 504 Sigvaris 902 + Sigvaris 504

Compression class and pressures (mmHg) (Hosy measurement method)

class 1; 18-21

class 2; 25-32

class 2; 25-32

class 2; 25-32

class 3; 36-46

class 1 + class 1 class I + class 2 class 1 + class 2 class 2 + class 2 class 2 + class 2 class 2 + class 2 class 1 + class 3 class 2 + class 3 class 2 + class 3

pressures through the four points from the wrist to the top of the arm was apparent in 50% of the 126 measurements taken. In 22% of the readings, one of the top of the arm pres­sures was higher than the lower arm pressures, suggesting that the profile was not evenly graduated.

Proportion of wrist compression at the top of the arm The values for median top of arm pressure expressed as a percentage of the wrist pressure were calculated as 41-64% for single-layer sleeves and 51-90% when two layers were applied.

Study discussion The results showed that the sleeves and sleeve combinations provided different pressure profiles when applied to differ­ent patients. The pressures exerted by differently styled sleeves of the same compression class also varied when used in the same patient. The pressure profiles exerted by garments do not appear to be standard, even in garments of the same compression class, and may be influenced by a combination of factors (Table 3).

When selecting garments for patients, factors such as limb size and shape, condition of the skin and subcutaneous tissues, and motivation to wear the garment should be considered. Knitting technique, materials used and compres­sion value also affect the way a garment performs and may influence garment choice. For example, a patient with a mildly swollen, well-shaped limb may be most comfortable in a Lycra-based garment that conforms to the shape of the limb. Another patient who has recently finished a course of intensive therapy, or is overweight with an arm that tends to become 'sausage-shaped', may do better in a thicker, more rigid garment which is less likely to conform to the poor limb shape.

Of particular interest are the results of the individual pressure profiles which indicated that garments did not consistently

Table 2 Median and range of interface pressures (mmHg) for 14 sleeve combinations

Position 1 Position 2 Position 3 Position 4 % wrist pressure at (wrist) (5 em below epicondyle) (5 em above epicondyle) (top of upper, outer arm) top of arm

Sleeve Median Range Median Range Median Range Median Range Median Range

MEDI 710 22 15-31 19 7-26 17 13-31 11 7-16 50 23-106 MEDI 712 27 21-33 20 10-27 18 13-27 16 10-22 59 33-105 SIG 902 22 17-34 23 8-26 20 14-25 14 6-20 64 18-91 SIG 503 32 22-56 23 14-30 18 12-29 13 3-23 41 5-85 SIG 504 22 12-34 27 18-32 28 11-33 14 7-24 64 44-100 710 + 710 35 25-48 33 18-51 28 22-32 25 13-29 71 27-100 710+712 38 34-51 35 25-42 32 24-34 26 17-32 68 33-94 710 + 503 47 39-51 34 27-42 29 17-43 24 6-32 51 12-79 712+712 48 44-62 42 36-51 34 26-39 29 25-52 60 42-93 712 + 503 50 41-57 40 35-47 34 22-42 30 17-42 60 38-74 902 + 503 41 30-48 37 28-45 33 17-46 25 11-36 61 29-83 710 + 504 39 21-49 38 36-55 40 23-46 31 21-41 80 64-110 712 + 504 38 36-50 46 33-64 41 22-47 34 18-37 90 50-100 902 + 504 37 20-57 45 30-55 43 26-53 23 17-42 62 55-115

Table 3 Factors to consider in choosing compression garments

Patient factors

Size and shape of limb

Changes in skin and subcutaneous tissues

Extent of fibrosis/fat deposition

Patient mobility and limb function

Ability to apply garment correctly

Patient motivation with regard to wearing the garment

Garment factors

Knitting technique

Fibres used

Compression class

Style and size

Condition and age

provide graduated compression towards the root of a limb. Although the most effective pressure profile for lymphoedema is not known, Partsch7 has previously described the difficulties in achieving graduated compres~ sion in extreme leg shapes. This may reflect LaPlaces's law which states: pressure = garment tension/limb circumfer­ence, as the circumference gradient of a poorly shaped limb is likely to be erratic. Other studies have also suggested that pressures are affected by the variations in circumference and distortions in shape along the length of the limb:

'a stocking can truly be said to produce graduated compression only when matched with a patient's leg, as the compression depends not only on the stocking's tension but also on the way it matches the leg in size and shape' 17

In practice, patients have very different shaped limbs, and limb shape also alters over a 24-hour period. While standard garments are used in the majority of patients, these observa­tions highlight the need to accurately assess limb shape and identify poorly shaped limbs that are not suitable for 'off­the-shelf' hosiery.

Double-layer sleeves used in the study did not produce double the levels of pressure although they did result in significantly high pressures at the top of the arm. When top­arm pressures were expressed as a percentage of the wrist pressure, the results, particularly in double-layer hosiery, were surprisingly high, ranging from 51 to 90%. These values, and the range 41-64% achieved with single-layer garments, are higher than the value of 40% illustrated in Figure 2 and described in hosiery company literature as reflecting a 'physiologically correct compression gradient' (Sigvaris).

Clinical experience suggests that double-layer hosiery may be useful in some patients, although the findings from this study suggest that care must be taken to avoid the risk of further complications. As previously reported, compres­sion garments are thought to counteract venous and lymphatic hypertension. Studies into blood flow in axillary

Journal of Tissue Viability 1999 Vol 9 No 3 93

and subclavian veins have demonstrated a degree of venous outflow obstruction in 71% of women with breast cancer-related lymphoedema 18 . Clearly, garments that exert high pressures at the top of the arm may exacerbate venous and lymphatic hypertension, particularly when the arm is at rest. This may lead to further problems such as peripheral swelling of the hand.

Limitations This small study raises some important points. However, it does have a number of limitations. A limited range of sleeves was studied in a small convenience sample of nine women with breast cancer-related lymphoedema. The sleeve combinations were chosen for study purposes, and many of the double-layer combinations would not be readily used in clinical practice.

The Oxford Pressure Monitor was used to record resting pressures only. It is reasonable to suppose that there are differences between resting and working pressures, and, indeed, it is likely that the compression garments probably achieve their main clinical effect while the limb is active. However, it was beyond the scope of this study to examine working pressures. The study was also limited to measuring pressures between sleeve and skin, and these do not neces­sarily correlate with pressures within the tissues, blood vessels and lymphatic system.

Conclusions and implications for practice and research The results clearly indicate that the apparently simple task of selecting a compression sleeve as part of the management of lymphoedema is in fact a complex endeavour. As such, thorough assessment of the limb and the patient is required, and there should be regular follow-up by someone with expertise and specific knowledge of compression garments. Clinics need to make available different styles and sizes of garments from various manufacturers, provide at least two new garments at each fitting, and ensure there is provision for made-to-measure hosiery. Education is also important to ensure that patients with newly fitted hosiery are aware of signs such as distortions in shape, skin redness or damage and peripheral swelling, which may indicate that their garment is unsuitable. Patients should be fully advised on the wearing, application and care of garments and encour­aged to contact the clinic if problems arise.

In the UK, an apparatus called the 'Hatra tester' 19 is used to determine the compression exerted by hosiery. It is possible that this does not reflect the action of sleeves on human limbs, and this study has highlighted some of the complexi­ties surrounding the use of compression therapy in lymphoedema. Future research using a wider range of garments in different patient groups is clearly indicated to develop knowledge and ensure more effective use of compression garments in the management of lymphoedema.

94 Journal of Tissue Viability 1999 Vol 9 No 3

Further consideration should also be given to other factors such as how changes in skin and underlying tissues influ­ence pressure levels, and the impact of compression therapy on quality of life.

Acknowledgements The authors would like to thank the patients of the Lymphoedema Clinic, Sir Michael Sobell House, Oxford, who kindly agreed to take part in the pilot study. Also thanks to Medi UK Ltd and Sigvaris (Britain) Ltd for their support.

Address for correspondence AE Williams, Optimal Healthcare Solutions Limited, International House, 7 High Street, Ealing, London W5 5DB. Tel: 0181 799 5027/0181 990 2529; fax: 0181 840 5142; e-mail: aew32910@ggr.co.uk

References Mortimer PS, Bates DO, Brassington HD, Stanton AWB, Strachan DP, Levick JR. The prevalence of arm oedema following treatment for breast cancer. Quarterly Journal of Medicine 1996; 89: 377-380.

2 Tobin MB, Lacey HJ, Meyer L, Mortimer PS. The psychological morbidity of breast cancer-related arm swelling. Cancer 1993; 72: 3248-3252.

3 Mortimer PS. Managing lymphoedema. Clinics in Dermatology 1995; 13(5): 499-505.

4 Fi:ildi E, Fi:ildi M, Weissleder H. Conservative treatment of lymphoedema of the limbs. Angiology 1985; 36: 171-180.

5 Christopoulos D, Nicolaides AN, Belcaro G, Duffy P. The effect of elastic compression on calf muscle pump function. Phlebology 1990; 5: 13-19.

6 Struckmann J. Compression stockings and their effect on the venous pump- a comparative study. Phlebology 1996; 1: 37-45.

7 Partsch H. Do we need firm compression stockings exerting high pressures? Vascular Service 1984; 13: 52-57.

8 Neumann HAM, Veraart JCJM. The use of medical elastic compression hosiery in phlebology. Phlebology 1995; 2 (Suppl1): 1153-1155.

9 Sarin S, Abu-Own A. Mechanism of action of compression therapy in venous disease; a review. Scope on Phlebology and Lymphology 1994; 1(3): 4-6.

10 Vandongen YK, Rashid P, Stacey MC. The effectiveness of compression stockings in reducing lipodermatosclerosis. Phlebology 1995; 2 (Suppl1): 862-864.

11 Bertelli G, Venturini M, Forno G, Macchiavello F, Dini D. Analysis of prognostic factors in response to conservative treatment of post­mastectomy lymphoedema. Surgery, Gynecology and Obstetrics 1992; 175: 455-460.

12 Bates DO, Stanton AWB, Levick JR, Mortimer PS. The effect of hosiery on interstitial fluid pressure and arm volume fluctuations in breast cancer related arm oedema. Phlebology 1995; 10(1): 46--50.

13 Badger C. Treating lymphoedema. Nursing Times 1996; 94(11): 84-88.

14 Todd J. Living with lymphoedema: your guide to treatment. London: Marie Curie Cancer Care, 1996.

15 Wytch R, Neil G, Kalisse G. Skin-orthosis interface pressure transducers: a review. Care Science and Practice 1986; 7(4): 100-104.

16 Kuhnke E. Volumbestimmung aus umfangmessungen. Folia Angiologica 1976; 24: 228-232.

17 Cornwall N, Dore CJ, Lewis JD. Graduated compression and its relation to venous filling time. British Medical Journal 1987; 295: 1087-1090.

18 Svensson WE, Mortimer PS, Tohno E, Cosgrove DR. Colour Doppler demonstrates venous flow abnormalities in breast cancer patients with chronic arm swelling. European Journal of Cancer 1994; 30A: 657--660.

19 British Standard Specification for Graduated Compression Hosiery: BS6612. London: British Standards Institution (BSI), 1985.

NOTIFICATION OF ANNUAL GENERAL MEETING FOR 1999

The Annual General Meeting of the Society will take place during the Society's 33rd Conference at the University of Southampton on 14 September 1999

Members wishing to raise any matters at the meeting are asked to inform the business manager by Monday 30 August 1999.

Members of the Society who are unable to attend the AGM can obtain copies of the Annual Report and Accounts by contacting the Tissue Viability Society office after the AGM.