Proper selection and sizing of compression hosiery can be confusing, but both are essential for control of edema and management of more serious vascular conditions in patients with diabetes. And then there’s the even more challenging issue of patient compliance.
By Shalmali Pal
Fit shoes in the afternoon and compression stockings in the morning. That’s the simple but effective rule that works for Bill Meanwell, CPed, founder, CEO, and director of the International School of Pedorthics in Broken Arrow, OK.
Marybeth Crane, MS, DPM, FACFAS, CWS, managing partner at Foot and Ankle Associates of North Texas in Grapevine, also follows a similarly streamlined model.
“For diabetics, usually we use 15 to 20 mmHg compression for those with edema and 10 to 15 mmHg for those without. Anything higher than 20 mmHg compression, patients should be custom measured by a physician, especially if they have peripheral arterial disease,” she said.
Indeed, the application of compression stockings would seem to be fairly cut and dry: Take leg measurements, use the manufacturer’s guidelines for determining the level of compression, choose a style, and hand over to the patient.
But not all diabetic patients are created equal, and neither are compression stockings. At one end of the spectrum are patients who may benefit from support pantyhose for light pressure to prevent or reduce mild swelling, a condition that is not only uncomfortable but can delay wound healing in diabetic patients. At the other end are those who suffer from significant edema or venous leg ulcers who are candidates for prescription-strength compression stockings. And then there are patients with peripheral arterial disease (PAD) and peripheral vascular disease (PVD). Issues that need to be addressed when prescribing compression hosiery include proper diagnosis, accurate measurements, and, of course, patient compliance.
Spotting vascular issues
While it may seem obvious, PAD and PVD require consideration beyond a visibly swollen leg, said David G. Armstrong, DPM, MD, PhD, professor of surgery at the University of Arizona College of Medicine and director of Southern Arizona Limb Salvage Alliance (SALSA), both in Tucson.
Some, but not all PAD and PVD sufferers, will show signs of intermittent claudication. But if the patient never walks far or long enough for leg pain or cramps to set in, then claudication may not manifest. Other symptoms to look for include:
- Weak or tired legs
- Difficulty with walking or balance
- Cold and numb toes or feet
- Slow-healing sores
- Foot pain even while at rest
The prescription for compression hosiery in diabetic patients with PAD or PVD needs to come from a clinician. Armstrong offered a general guideline for when compression hosiery are appropriate.
“As long as the patient doesn’t have tremendously low outflow pressure into the extremity, I think it’s safe for them to wear compression hose,” he said. “If their outflow pressure is below the relatively mild amount of pressure applied by a compression stocking–for example, if the outflow pressure is below 30 or 40 mmHg–then that’s significant ischemia and the person has bigger problems that just swollen legs. They should be evaluated promptly by a vascular surgeon. The key is knowing this and measuring it. As we often say at SALSA, ‘You can’t manage what you can’t measure’.”
Measure for measure
Improper compression hosiery usage and incorrect sizing has been a recognized problem in the foot health community, but not necessarily well documented. Graduated compression socks that are sized incorrectly may actually increase the incidence of vascular disease and may even lead to skin breakdown, neither of which are ideal in any patient, diabetic or otherwise. In a study published in the August 2002 issue of Medsurg Nursing, a group of nurses was interviewed about their fit technique for graduated compression stockings, and only two of 15 said that they measured the patient’s leg to determine the correct size.
In a 2008 study, researchers at Presbyterian Hospital in Dallas sought to determine if healthcare practitioners were correctly sizing compression stockings, how the patients rated the comfort level of the stockings, and whether they understood the purpose of the hosiery. The study population was made up of hospitalized, postoperative patients, and nurses dispensed the stockings, but the results can be applied to diabetic patients as well, according to lead author Elizabeth H. Winslow, PhD, RN, FAAN.
While it is important to note that there are differences between postop patients and diabetic patients in terms of their compression needs, a good fit is a universal must. Additionally, many of the issues that Winslow’s group saw in their study population may also crop up with diabetic patients.
“Any patient who has compression stockings prescribed needs to wear the appropriate size; know how to size, and use the stockings correctly,” Winslow said. “Patients, and their family members, also need to realize that the leg size may change. If swelling significantly increases or decreases, the patient will need to be re-measured to determine if another size is needed.”
The final study group consisted of 142 patients, the majority of whom (74%) were overweight. The most common type of surgery was gynecological (53%) followed by orthopedic surgery (41%). Seventy-four percent of all patients were prescribed knee-length stockings, and 26% wore thigh-length stockings.
Winslow and coauthor Debra Brosz, MSN, RN, ONC, NEA-BC, found that the compression stockings were used incorrectly in 29% of the patients, with the most common problems being that the stockings were rolled down or too loose. The authors did not ascertain if the stockings were deliberately rolled down by patients, Winslow said. But diabetic patients will be tempted to turn down the band at the top of the stockings, especially if the leg swells and the hosiery feels tighter.
Also, patients with a thigh circumference of greater than 25 inches were given thigh-high stockings when knee-length would have been more appropriate. However, a larger size than appropriate was prescribed in 26% of the patients wearing knee-length hosiery. In patients with a body mass index of 25 or more, the thigh-length stockings were more likely to be used improperly than the knee-length stockings. The findings were published in the September 2008 issue of the American Journal of Nursing.
The authors acknowledged that, in some cases, stockings were initially sized correctly, but subsequent swelling brought on changes to the patients’ needs (see Tables 1 and 2). Winslow also pointed out that patients with neuropathy “may have difficulty feeling any pressure areas or problems from the stockings until serious skin damage has occurred.” Again, stockings need to be measured and re-measured to meet the patient’s evolving needs.
Nancy Elftman, CO, CPed, stressed the importance of obtaining Ankle-Brachial Index (ABI) measurements.
“You have to know the ABI to put the stocking on,” said Elftman, founder of Hands on Foot in La Verne, CA. “If the ABI is less than 0.6, then it’s an arterial disease, not a venous disease, and you cannot put compression on it.”
Compression can actually worsen the already limited blood flow in patients with peripheral arterial disease and potentially induce ischemia.
“If (the ABI) between 0.6 and 0.8, then it’s a combination of venous and arterial and for that, you can only use a 20 mmHg stocking. If it’s a 0.8 to a 1.0 ABI, then that’s purely venous and you can use a 30-40 mmHg,” Elftman added. (see Table 3).
Knee vs thigh
In Winslow’s study, patients expressed a preference for knee-high stockings over thigh-high ones. They also found that more problems arose when patients were given thigh-high stockings. Their findings led to a policy change at their institution: Nurses are encouraged to work with physicians and nurse practitioners to make sure that knee-length stockings are prescribed. In addition, “we have removed the thigh-length stockings from all of our buildings.”
A patient survey done at California State University in Sacramento found that knee-length sequential compression devices for preventing deep venous thrombosis were more comfortable for patients, encouraged a higher level of compliance with treatment, and were less expensive. That study was published in the July/September 2007 issue of Critical Care Nursing Quarterly.
A systematic review of 14 randomized trials in hospitalized populations and passengers on long haul flights found that knee-length stockings did not appear to be worse than thigh length in hospitalized patients. That study, published in the December 2006 issue of the European Journal of Vascular and Endovascular surgery, found that knee-length stockings were actually better in passengers in flight for preventing DVT.
An earlier study done at Semmelweis University in Budapest, noted knee stockings were less efficient at increasing venous outflow in postoperative patients, although they were deemed more comfortable and less likely to wrinkle. Those findings were reported in the February 2001 issue of Clinical Orthopaedics and Related Research.
But Elftman said that, in her experience, there are really only two circumstances where a thigh length stocking would be more appropriate in diabetic patients: If the patient has lymphedema, or if the patient prefers a longer stocking.
“Women, especially if they wear skirts, want [the stocking] to be up higher. Some patients have trouble with knee stockings rolling down so they’d rather have it go up higher. But as far as the physiological effects, the knee down is what you are working on,” she said.
Elftman pointed out that, according to noted vascular surgeon John Bergan, MD, founder of the Vein Institute of La Jolla in California, “it really doesn’t do any good in terms of compression to go to the thigh. There is so much volume in the thigh, it’s not really producing hydraulic compression. He says go to the knee unless they feel better having a higher stocking. It would be for patient preference, not for the compression.”
Armstrong said that at his institution, knee highs are preferred over thigh highs because many of the patients simply cannot manage longer stockings. The hemmed band can be difficult to negotiate over a thigh with a larger circumference, while the stockings that are attached with a bit may prove tricky to attach.
Compression and compliance
An October 2006 study published in the Journal of Vascular Surgery looked at the prevention of venous ulceration recurrence using class 2 and class 3 elastic compression. No surprise that the lowest recurrence rate was seen in patients who wore the highest degree of compression. The authors concluded that “patients should wear the highest level of compression that is comfortable.”
But the most effective level of compression and patient comfort don’t always jibe. One of the best ways to ensure compliance is to, once again, make sure that the stocking has been properly fitted. In Winslow’s study, one of the most common problems with the thigh-high stockings is that they were rolled down.
Another key is making sure that the patient understands what the intention is behind the compression stocking.
“As clinicians, you can’t assume that just because you said something, someone knows it and internalizes it. The key for clinicians treating people at high risk is to stay on-message. Every single person that sees a patient has to be talking to him with that same message. The more you drive home that message, the better adherence will be,” Armstrong said.
Elftman said she first does a trial run.
“We take the measurements together and then we put [the patient] in an Unna boot or an Ace wrap for a week,” she said. “They come back and we do the measurements again. Just during that week, they can see the difference, the decrease in the size of the leg. So by the time we measure for the stockings, [the patient has] seen the decrease and are much more compliant. You really have to build them up to it.”
Elftman also drives home that the stockings must be removed every night. Because the stockings can be difficult to put on, some patients prefer to leave them in place, but Elftman strongly discourages that, explaining to the patient that the small radius of compression in the heel could cause an ischemic ulcer.
Even if the patient comprehends the point of the stocking, clinicians also need to look beyond their vascular issues. Armstrong shared the case of a patient with mixed arteriovenous disease who needed to wear his compression hosiery. But Armstrong’s team had to overcome a major obstacle before they could get this patient into his stockings.
“(This patient) had some substance abuse problems,” Armstrong explained. “He was self-medicating when he initially came to see us and, in a fit of mania, he had ground a hole into his ankle and part of his foot with a PedEgg callus trimming device. He was committed to using that PedEgg on his calluses. We had to convince him that the hole in his skin was not a positive result of his PedEgg regimen. But when we tried to take the PedEgg away from him, he totally shut down. We were unable to communicate and he refused to even work with us. So instead of taking away the PedEgg, we focused on teaching him how to use it appropriately and safely—and checking in on him frequently.”
Once the wounds had healed, and Armstrong’s team were confident that the patient understood how to use his pedicure aid properly, the stockings were introduced.
“He is now very adherent, uses his hose diligently, and reports to us regularly and passionately about his stockings and his PedEgg use. He is now a partner rather than an opponent,” Armstrong said.
Compression stocking measurements: Dos and Don’ts
- Do measure and fit the stockings according to the manufacturer’s recommendation.
- Do document leg measurements and stocking size at baseline.
- Do check the stockings to ensure correct usage and adequate perfusion.
- Don’t assume that leg measurements are set in stone. Review measurements regularly to check for swelling and excessive pressure from the stockings.
- Don’t let the patient go for more than one day without removing the stockings and performing a skin assessment.
- Don’t monitor patients while they are lying down. Placing the patient in a seated position can help determine if the stockings are acting like a tourniquet.
Source: Adapted from Best Practice: Graduated compression stockings for the prevention of post-operative venous thromboembolism 12:4, 1-4, 2008, The Joanna Briggs Institute
Seven steps to obtaining the right measurements
1. Measure the circumference of the ankle around the narrowest part, above the ankle bone.
2. Measure the circumference of the widest part of the calf.
3. Measure the length of the calf from the back of the heel to the bend in the knee.
4. Measure the circumference of the widest part of the thigh just below the gluteal fold.
5. Measure the length of the thigh from the gluteal fold to the back of the heel.
6. Measure the circumference of the widest part of the hips.
7. Measure the circumference of the waist.
- Sphygmomanometer with appropriately sized cuff(s) for both arm and ankle
- Hand-held Doppler ultrasound device with vascular probe
- Conductivity gel compatible with Dipper ultrasound device
1. Measure brachial systolic pressure in both arms.
2. Measure posterial tibial and dorsalis pedis systolic pressures in both legs.
3. Divide each ankle systolic pressure by the brachial systolic pressure.
- Normal: 1.0-1.1
- Borderline: 0.91-0.99
- Abnormal: <0.9 or >1.3
Source: Adapted from Ankle-Brachial Index: A Diagnostic Tool for Peripheral Arterial Disease, American Academy of Nurse Practitioners
Compression cross-checked: Flight-related data and diabetes
The subject of vascular problems and long-haul flights has taken off in recent years. Multiple studies have shown that being airborne for more than 10 hours increases the risk of deep venous thrombosis (DVT) or edema. However, the risk of both conditions can be reduced with compression hosiery.
The question for lower extremity practitioners is: Is the research on “travel stockings” relevant for diabetic patients? Yes, according to Armstrong.
“I think these (results) apply equally to people with and without diabetes,” he said. “The key for the people with diabetes is that they are under the care of a diabetologist, a vascular specialist, and a foot specialist. You have to make sure that they’ve been properly assessed by one or all of those specialists in terms of their risk for DVT.”
Results from the LONFLIT4-Concorde study are the most relevant to diabetic patients. Conducted by the A San Valentino Vascular Screening Project in Chieti, Italy, the study evaluated edema during seven to eight hours flights and whether it could be controlled with compression stockings (20 to 30 mmHg). There were 144 subjects (74 in the stocking group and 76 in the control group), all of whom had edema-associated microangiopathy from diabetes, venous hypertension, or anti-hypertensive treatment.
The level of edema was comparable in the two groups at baseline. Post-flight, the stocking group’s average edema score was three times lower than in the control group (P < 0.05). Also, there were no cases of DVT in the stocking group, compared to a 3% incidence in the control group. The level of compression was well tolerated in both groups. The results were published in the March-April 2003 issue of Angiology.
Sponsored by an educational grant from Dr. Comfort