Patient compliance is often cited as hindering compression therapy outcomes. But, in fact, practitioners themselves may be to blame for not ensuring that stockings are fit properly and that patients know how to wear them correctly.

By Linda Weber

Routinely prescribed for patients with deep vein thrombosis, gradient compression stockings are a tried and true treatment option for the accumulation of fluid in the lower extremities. DVT is associated with edema, venous stasis dermatitis, venous stasis ulcers, and increased risk of pulmonary and other forms of embolism.

The approximately 600,000 individuals in the United States affected by DVT every year are primarily an older patient population, often plagued by limited mobility and dexterity. For these clients, the stockings are a hard sell. They balk at how difficult they are to put on, and the stockings’ unattractiveness isn’t much of an incentive. On top of that, patients are often disheartened by the news that they’ll need to wear the hosiery for the rest of their lives. That’s why practitioners often cite patient compliance as a key component of treatment that needs improvement.

But, in fact, practitioners themselves may be hindering treatment outcomes. A study published in the September 2008 issue of the American Journal of Nursing showed that in 142 hospitalized, postoperative patients, graduated stockings were sized incorrectly in 26% of patients. The study also revealed that 29% of patients used the stockings incorrectly, which was especially true in overweight patients who wore thigh-length stockings.

“Putting compression stockings on is like going 10 rounds of boxing. Not every patient can do it,” said Mark Hinkes, DPM, chief of the podiatry section at the Veterans Affairs Medical Centers in Nashville and Murfeesboro, TN, where the majority of his patients are diabetic.

Improper fit can have serious consequences, such as necrotic tissue damage, trauma, and possible ulceration. But reviewing the steps practitioners need to take when fitting patients with stockings can help avoid these sequelae and may improve the stockings’ preventive capabilities.

Compression hosiery works by applying graduated, sustained pressure to the lower leg, delivering more pressure at the ankle and decreasing pressure in a proximal direction. This pressure reduces edema, improves venous blood flow return to the heart, and prevents blood pooling, and possibly clotting, in the legs.

According to an overview of compression hosiery in the April 2008 issue of US Pharmacist, the optimal degree of graduated pressure that’s been shown to increase venous flow the most in nonambulatory patients is 18mmHg at the ankle, decreasing gradually to 8 mmHg at the knee.

Pressure-based classification

Stockings come in different pressure classes, based on the amount of pressure applied at the ankle, which correspond to indications of increasing severity.

• For less severe symptoms including spider veins, early varicose veins, aching feet and legs, and slight edema, the 8-15 mmHg of pressure provided by commerically available support hose is usually sufficient.
• For varicose veins, mild edema, and DVT prevention, Class 1 hosiery (14-17 mmHg or 15-20 mmHg) is recommended.
• For moderate varicose veins, mild edema, and prevention of venous ulcer recurrence, Class 2 hosiery (18-24 mmHg or 20-30mmHg) is indicated.
• For severe varicose veins, lymphedema, treatment after phlebitis, and to prevent and treat venous ulcers, Class 3 hosiery is required.

“I look at patients in terms of where they fall on the swelling spectrum,” said Loraine Lovejoy-Evans, PT, DPT, CLT-Földi, owner of Independence Through Physical Therapy in Sequim, WA.

On the left side of the spectrum are those with minimal swelling, on the right those with severe swelling. Lovejoy-Evans maintains that the longer a patient’s swelling has been present, the farther the patient moves to the right side of the spectrum. And the amount of swelling dictates the degree of compression needed.

“The greater the swelling, the tighter the compression garment required,” Lovejoy-Evans said.

She also teaches her patients a Manual Lymphatic Drainage (MLD) technique they self-administer on bare skin to promote proximal suction of fluid to the heart. But whether they use the drainage technique or not, she says, any patient who presents with obvious signs of swelling pathologies goes into a graduated compression stocking.

The fitting process

Fitting begins with accurate measurements taken as early in the day as possible, before fluid has accumulated. If needed, the patient’s limbs are bandaged to reduce swelling prior to measuring.

With the patient sitting, feet flat on the floor, the practitioner uses a measuring tape to measure the calf at its widest point and the ankle at its narrowest point for over-the-counter garments. Measurements are taken for both legs, since they can differ. Measuring for custom-fit garments requires training from the manufacturer. When Lovejoy-Evans removes the patient’s stocking, she re-measures to make sure the leg’s girth hasn’t increased.

“After measuring the patient, we put the pressure garment on the limb,” Lovejoy-Evans said. “We make sure we can’t lift any fabric easily along the length of the tube. We also watch for signs of gapping, wrinkling, or other obvious fit issues.”

Typically, she first tries 20-30mmHg garments. If that fails to stop the swelling, she moves up to 30-40mmHg. If the girth of the limb increases more than 2 cm despite the stocking, she recommends custom-fit, flat-knit garments or another alternative such as a non-elastic adjustable compression product.

Patients are taught how to don the stockings.

“We have a loaner library of knee-high compression garments in the clinic in various sizes and fabrics,” Lovejoy-Evans said.

Additional assistance

During and after the fitting, the practitioner gives tips or recommends an assistive device to help put stockings on. Lovejoy-Evans shows patients some of the various donning/doffing devices in her loaner library.

“Our favorite is something called a Slippie Gator, a slippery sleeve that goes inside the stocking, making it easier to slide the hosiery up the leg. We also demonstrate using gardening gloves,” she said.

Hinkes recommends another variation called the Butler Stocking Aid, a wire structure that supports the stocking while the patient slips in their foot, then is removed.

If patients have the cognitive ability and hip mobility to use the recommended device, they take one home.

“If they find that it works, we have them purchase one,” she said.

Ideally, patients come back within a week so the therapist can check  that the hosiery is being worn correctly and verify that the patient has been following instructions.

“If they’re not donning the sock until they have been up for a few hours, they swell. If they wear the sock for two or more days in a row, they swell,” Lovejoy-Evans explained.

If the swelling in the limb has increased by more than 2 centimeters, she considers the intervention a failure and tries to pinpoint whether the garment or lack of compliance is at fault.

“I recommend patients remain in compression garments until they go to bed.  If they have a limited supply of garments and they need to be laundered, I have them remove them one to two hours before bed to launder,” Lovejoy-Evans said.

Style considerations

Both Hinkes and Lovejoy-Evans primarily use knee-high garments.

“I find that some patients who should wear thigh-high stockings refuse them. Other patients will wear toeless stockings, which are cooler and can be worn with sandals, but they’ll refuse a closed-toe stocking,” Lovejoy-Evans said. “My philosophy as a clinician is that the best compression garment is whatever the patient will use.”

Hinkes prefers closed-toe stockings for the majority of his patients..

“If the toes are swollen, open-toe stockings dig into the skin and  can even cut it,” he said. “I only use open-toe  hosiery in very mild cases.”

Lovejoy-Evans  pointed out another disadvantage to open-toe stockings—they can ride up, which allows fluid to pool in the forefoot. That causes the stocking to creep toward the heel, leaving more of the forefoot out of compression.

Not all patients with edema will be candidates for compression stockings.

“Some obese patients have 18 to 24 inch calves. It’s not reasonable to expect that they can wear these stockings,” Hinkes said. “In many cases, even when patients in this situation are successful in applying the stockings, they can not tolerate the compression and unfortunately remove the stockings due to pain.”

And then there are patients who are too physically weak, don’t have the flexibility, or lack the cognitive wherewithal to use them.

One alternative for some patients is a pneumatic compression device, or pump, that can be rented or purchased. Hinkes particularly recommends “active” pumps that move fluid out of the limb using peristaltic contractions.

“The pneumatic compression pump removes the fluid from the legs in segments in patients who cannot tolerate or cannot wear compression stockings, and makes sure it doesn’t drop back,” Hinkes said. “If you pump twice a day, you do not need compression stockings.”

However, in his estimation, only about 7% to 10% of eligible patients use the pump, for two reasons. One is a lack of information about the latest technology. The other is cost.

“The cost of three pairs of compression stockings does not even come near the price of a $5,000 pneumatic compression device,” he said. “In the age of cost containment and close scrutiny by insurance companies, there is real pressure to prescribe the most cost effective care, which may not always be the best choice of treatment.”

Contraindications for compression stockings and pneumatic compression devices are similar. Neither form of compression therapy should be used in patients who don’t have good arterial circulation.

Motivational strategies

Both Lovejoy-Evans and Hinkes have strategies they use with patients who are reluctant or unwilling to wear their compression stockings.

“I recommend that they use the socks for two or three days, then stop wearing them for two or three days and see if they notice any changes in their symptoms,” Lovejoy-Evans said.

If the patient still resists, Lovejoy-Evans explains that she’s seen the treatment work on thousands of people, but that it’s up to the individual to make the choice. She also suggests that the person may want to reconsider in future if the symptoms worsen and become less tolerable than wearing the stockings.

Hinkes’ approach is based on creating a partnership with patients.

“Fear does not motivate patients,” he said. “Find out what’s important to them: Seeing their grandchildren, going for a walk, hunting or fishing. They have to know the benefits— what makes it worth it for them to do this.”

Linda Weber is a freelance writer based in Clemmons, NC.