Compression stockings 

When are compression stockings used?

 

Usually, compression bandages are used when the patient has leg ulcers.  Compression bandages are easier to apply when a dressing is attached to the leg. Compression stockings are most commonly used once the ulcer has diminished considerably and only a small dressing is necessary. Compression stockings are also used after the ulcer is healed to prevent a recurrence.  For most people, it is more acceptable to use a compression stocking for the rest of their lives rather than a more bulky compression bandage.  Compression stockings are also used to prevent ulcers from developing - i.e., as a prophylactic measure in patients with incompetent veins. If you have a patient who has venous insufficiency, our clear advice should be to start using daily compression to slow down the worsening of the venous flow. 

Do you work in a large city in Africa? In that case, you may have a trained fitter who sells compression stockings.

There may be sellers of compression stockings in some urban areas in Africa who are specialized fitters of compression hosiery.  We do not currently have a list of where to find these in most African countries, but we are working on mapping out such a network.  Check around if you, by chance, have such trained sellers in your area. A trained fitter will have much expertise to do the correct fitting measurements and choose a compression stocking that best fits the patients' needs.

 

Also, if you live in an urban area, this must undoubtedly be a niche for someone to start their own business - becoming a professional fitter of compression garments.  We believe that if you contacted some of the major producers, they may likely even help you with the formal training.  Just as an idea, if any of our readers are looking for an alternative career!

  

What are the differences between regular compression stockings and medical-grade compression stockings?

There is a jungle of producers on the market selling compression stockings of highly varying quality.  If your patient has limited resources, one may have to settle for a cheaper and possibly suboptimal compression stocking.

High-quality compression stockings for treating venous ulcers and venous disorders, in general, are labeled medical-grade compression stockings.  These are certified compression stockings that guarantee a specified compression level according to which class of compression stocking you choose. Much cheaper, non-certified compression stockings have a compression strength similar to Class I compression devices- that is the weakest compression level. This may not necessarily be bad - in the start, it may be wise to start with a low level of compression to get the patient used to it and go over to a Class 2 stocking after a month or so. Read more about the classes of compression stockings below. 

Again, it may be wise to buy a cheaper compression stocking initially, get the patient used to the treatment, and invest in a better, medical-grade stocking after a while. 

Which classes of medical compression stockings are there? 

Class 1 compression stockings have a compression strength of about 15-21 mmHg at the ankle height. They are recommended for more early venous disorders such as mild varicosis with only minor leg edema. If the patient has a history of venous ulcers or an active ulcer, this compression level is too weak to be very effective.  However, if the patient needs a class 2 compression garment but has never used compression before, it may be wise to start with a class1 stocking for the first few weeks to ensure better patient comfort ( read compliance). Also, Class 1 stockings are indicated in patients who have both a venous AND arterial disorder- i.e., poor arterial circulation.

For patients who find Class 2 compression stockings too tight but need these, a workaround can be to use two class 1 stockings on top of each other.  As mentioned earlier, this may result in a class 1,5 garment, which is slightly more comfortable than an actual class 2 stocking. If the patient uses the two stockings method, they can take off only the outer stocking at night and keep the other class 1 stocking on during sleep. This is, of course, optional, but it is easier to take on the other stocking the following morning with one stocking already in place. Also, having some slight compression at night is seen as positive.  As you will be aware by now, there are many tricks in the field of compression. Remember, our goal is to provide the patient with the most comfortable solution for them, so that patient compliance is as good as possible. 

Class 2 compression stockings provide a compression of 23-32 mmHg. Class 2 compression garments are recommended for use after surgery for incompetent veins, more prominent varicose veins, mild lymphoedema, after deep venous thrombosis, smaller venous ulcers, and after venous ulcers have healed.  Again, if your patient has never used compression before, it may be wise to start with a class 1 garment and go over to a class 2 stocking later once the patient is accustomed to using compression.

Class 3 compression stockings have a pressure of between 30-40 mmHg. These are indicated for more advanced edema - for example, lymphoedema.  It is not often we use these in the treatment of venous ulcers. Most patients will find them very tight, and they are also very hard to put on/take off. These types of compression stockings are usually used in clinics specializing in lymphoedema treatment. In many cases, these patients have challenging leg/thigh shapes with the need for individually tailored compression garments. 

Should you use a leg stocking or one which goes up to the thigh? 

This is up to patient preferences but also medical indications.  If the patient has enlarged varicose veins visible on the thigh or edema above the knee, one would recommend a long compression stocking. However, a long stocking is harder to put on and tends to curl downwards in the course of the day. Beware: Thigh-high compression stockings may create a tourniquet effect and cause localized restriction when rolled down! It is imperative to inform the patient about this and make sure they adjust and roll up the compression stocking as often as possible. 

 

Many patients are also not happy about using thigh-high compression.  In most cases, the main problems with venous insufficiency manifest themselves on the legs, and compression up to the knee is sufficient.  In the ideal world, we would love it if everybody with venous insufficiency wore compression up to the thigh as this will give the best return of blood, but this is just not realistic.   If you manage to convince the patient to use knee-high compression daily, you have come a long way!

Figure 1  Should your patient use knee-high compression or stockings which go up to the thigh?  In most cases, compression up to the knee is sufficient, but a compression stocking up to the thigh will undoubtedly provide the best blood return from the extremity.  It may also be a case of patient preference and financial resources. A long compression stocking is more expensive. 

Should the compression stocking have an open or closed toecap? 

 

Compression stockings come with open or closed-toe caps.  The stockings that are open at the toe areas are usually used in patients with deformities at the toes - for example, hammertoes or claw toes.  A closed stocking may be uncomfortable for these patients. Here also, patient preference has a role. Some patients prefer to have open toes when they go with sandals.  In Africa, many people use flip flops daily - it is not possible to use flip flops with a stocking that is closed at the toe area.

Figure 3 Compression stockings are available with open- or closed-toe areas. 

Can you use compression stockings when the patient has a venous ulcer? 

Absolutely, but if you have bulky dressing because the ulcer has much exudate ( as many venous ulcers have), stockings are difficult to put on without moving the dressing.  Also, the stockings are easily soiled if there is leakage of exudate. Another argument against stockings in this phase is that compression bandages remain on the leg night and day, providing compression over 24 hours.  Compression stockings are generally removed at night because most patients do not like to sleep with them.  For some reason, compression bandages are more comfortable to sleep with than compression stockings. We expect venous wounds to heal better if there is also some compression at night, so this is one of the reasons why many wound practitioners prefer using bandages instead of socks in a patient with active ulcers. 

 

In cases with smaller ulcers with low exudate ( i.e., thin dressings), compression stockings can be an excellent alternative to compression bandages. We heard that in Australia, many practitioners routinely use compression stockings to treat all sorts of venous ulcers. They argue that so many health care workers are not competent enough to apply a safe and effective compression bandage that it is safer to use compression stockings. 

If we use the hypothesis that it is more optimal to have some compression also at night, you could have the patient buy two class 1 stockings. During the day, they use both stockings on top of each other- at night, the patient takes off the outer stocking and sleeps with the inner stocking. 

Are some stockings easier to put on than others? 

Most patients find it very difficult to put on compression stockings, which is one of the reasons for low compliance.  Some patients find it downright impossible to put these stockings on if they, for example, are stiff in their back or the fingers or do not have the power in their arms/hands.  This makes them dependent on other family members or neighbors to help with the daily routine of taking off and putting on the stockings. In many western countries, home care nurses come to the patient's home to aid with taking off and on compression devices- just imagine- what a misuse of resources!  At the end of this chapter, we demonstrate some aids which make it easier to put on and take off compression stockings. Many patients find these very helpful and may make the patient independent from other help. 

Some producers sell compression stockings in a kit with an inner stocking as the first layer - this does not have any significant compression but aids in taking on the compression stocking.  The compression stocking is part two and is easily pulled over the inner stocking. 

Other producers have compression stockings with zippers on the sides, and most people will find these easier to use, but they are usually also more expensive.  Stockings with zippers typically come with an inner stocking as the base layer, and this combination usually delivers a pressure of between 30-40 mmHg. The inner stocking can be kept on at night.  Most producers have the zipper on either the left or right side - choose the one where the zipper side ends on the opposite side of the ulcer. 

Figure 3 Medical grade Stockings with an integrated zipper may make it considerably easier for the patient to put on /take off compression stockings. Usually, these are supplied with an inner layer stocking that is kept on both day and night, while the outer stocking with the zipper is taken off at night. The picture above shows the Ulcercare zipper version by  Jobst  ( copyright Jobst) 

Do compression stockings contain latex?

Most compression stockings from the primary producers do not contain latex, while some stockings have integrated latex. This is usually clearly marked on the box.  It should not be difficult for patients with latex allergies to find a latex-free alternative.   In general, the chances of the stocking containing latex are higher in cheaper alternatives.  Also, these products may not always be marked clearly if they contain latex. Suppose you are unsure but have no other options. In that case, the patient can use a thin, non-elastic stocking of cotton or other thin material as a base layer underneath the compression stocking to minimize skin contact.  Most patients do not have a latex allergy, and here the question is not of relevance. 

How many hours per day should the patient use compression stockings?

Previously it was an international recommendation that most patients remove compression stockings at night.  If we assume that most people sleep for about 8 hours, most patients use the stockings for about 16 hours a day, give or take a few hours. This recommendation is currently being challenged, and in some regions in the UK and Denmark, for example, many patients are now advised to sleep with their stockings on. This is in accordance with the hypothesis that it is better to have some compression during the night. This also makes the patients much more independent and may increase compliance with using compression. There are also substantial economic benefits for health authorities as home care nurses in western countries use considerable resources in helping patients take off/put on compression garments. 

However, sleeping with compression stockings is not recommended for all patients!  For example, patients with poor arterial circulation should have a break from compression at night. Also, patients with neuropathy in the legs are not advised to use compression stockings at night as they may not feel if the compression is too much. Some patients cannot sleep when they feel something tight around the leg- they also need to remove the stockings at night. 

 

Which time of the day is best to take measurements for the correct stocking size?

Compression stockings need to fit well to be effective and comfortable. Ideally, trained health care personnel should take measurements of the leg to assure that the patient receives a stocking with optimal fit.  It is quite unlikely that buying a stocking over the counter will fit well for the patient unless they can try it on first.

 

The best time of the day to take these measurements is in the early morning, when the edema in the leg is still low.  If the patient takes measurements in the afternoon, they likely end up with a too-large stocking.  It is not always practical for a patient to be measured in the morning, and in such cases, it is best to have the patient supine for at least 15 minutes with the leg elevated before taking the measurements.

Another important point: if the patient has very swollen legs, it is not wise to get them to buy compression stockings - within a few weeks, the edema may have subsided due to the compression, and the stockings will no longer fit - they will be too loose.  In these cases, get the patient started on compression bandages for one or two weeks until the worst of the edema has been reduced - then the patient can buy compression stockings.

Is it ok to use skin oils, lotions, or cremes under compression stockings? Or can this damage the stockings?  

Most skincare products based on oils or glycerol may damage the elasticity of the stockings and shorten their lifespan considerably.  The elastic part of the stockings is usually made of lycra, which is quite sensitive to such products.  Suppose the patient feels the need to use moisturizing products under compression hosiery. In that case, they could use an inelastic smooth inner stocking as a layer between the skincare products and the compression stocking.  

What are other obvious "Dont`s" when it comes to compression stockings?*

 

This is some of the information we have to give the patients along the way:

 

DON’T roll up your compression stockings to put them on or take them off. Rolling creates a tight band, which cuts off circulation and can cause sores. While donning or removing your compression socks, try not to roll or scrunch them up.

DON’T wear them at night unless this is part of the treatment plan prescribed to you. When lying down, your legs are already in a neutral position that allows regular blood flow. Adding graduated compression in this position increases circulation but once again is unnecessary. Try elevating your legs on a couple of pillows instead. By having your legs above your heart level, you facilitate regular blood flow.

DON’T use chlorine bleach to clean your stockings. Avoid using any substance that could damage your compression socks. Harsh chemicals like chlorine bleach should be avoided.

DON’T wring out compression socks to dry them. Any intense movements, such as wringing or scrubbing, can damage your stockings. Treat them gently to get the most out of them. To get the excess water out of your compression stockings, just ball them up and squeeze gently.

DON’T alter your compression stockings. Refrain from cutting off any part of your compression stockings. The foot of compression hosiery acts as an anchor; it provides a solid hold, making it easier to put on the stockings. Furthermore, compression stockings have graduated compression, meaning the compression is strongest at the ankle and gets lighter as it goes up the calf. Cutting off the foot could cause them to roll up and become uncomfortable to wear. If your stockings seem too tight around the toes, you may want to consider a product such as open-toe compression stockings.

* these Dont`s are reprinted here with kind permission by legsmart.com - an informative website on compression garments in the US. 

How do you take correct measurements for determining the right size of compression stockings?

Getting the correct measurements for compression stockings is one of the most important aspects of achieving a good fit. Some compression socks size use the patient's shoe size, but as you will appreciate, shoe size cannot determine the leg's correct shape.  Therefore most producers require simple measurements from the patient's leg. For leg compression stockings, only three measurements are needed.  The images below are reproduced with kind permission from legsmart.com in the USA

wounds africa  stokkings measure.JPG

Figure 5  Taking correct measurements for fitting a compression stocking is not very difficult.

Step 1) Ankle circumference: Measure the ankle in the smallest part of the ankle, just above the ankle bone.

Step2) Calf circumference: Measure the largest part of the calf. You may need to search for the largest part of the calf by measuring above and below the middle of the calf.

Step 3) Leg length: For the knee-high compression stocking, measure from the back of the bend of the knee to the floor behind your heel. Do not wear shoes as you will get an inaccurate measurement.

copyright: www.legsmart.com

wounds africa stokkings measure 2.JPG

Figure 6  Taking correct measurements for fitting a thigh-high compression stocking. Steps 1,2, and 3 are identical as in figure 5 for thigh-high compression stockings. In addition, we have to measure the following:

Step 4) Thigh circumference: Measure the largest part of the thigh at the top.

Step5) Thigh + Leg length: For thigh-high or waist-high, measure the length of the leg from the top of the thigh to the floor behind the heel.

copyright legsmart.com

What are the best aids for putting on/taking off a compression stocking?

We really cannot give you a definite answer to this question.  Firstly, this depends on whether the patient is using a stocking with a closed or open-toe area.  Other influencing factors are, for example, how much grip power the patient has in their fingers, how flexible they are in their backs and knees, and personal preferences. 

As you probably already know - using washing up gloves when putting on / taking off compression socks makes a huge difference. And they cost close to nothing and are available at most corner shops. Most washing-up gloves make it easier to grip the compression hosiery - you don't have to pinch the stocking to get a grip on it, and you can prevent tears in the stockings from fingernails.  So this is, without doubt, an essential part of your and your patient's toolbox if they use compression stockings.

There is a confusing variety of aids to choose from, and some of them are not intuitive the first time you use them.  Some are simple and easy to make yourself of smooth silk-like material.  Others are step-in frames which are usually not very expensive.  The important thing to remember is:  Almost all your patients will appreciate one or another of these aids.  We are often surprised about how few stocking users have heard about these aids. 

Figure 7  There is a confusing choice of donning aids available for compression stockings.  Not one of these will be suitable for the needs of all users.  Some of these are not as intuitive as they may appear and need some training. Which type of compression aid is most suitable for your patient depends on several factors - for example, whether the stocking is closed at the toe area or open and patient preferences.  The patient will be able to make some of these by himself out of cheap materials. 

Video 1  Some good advice from MEDI on hjow to put on compression stockings 

Video 1  Some good advice from MEDI on how to put on compression stockings 

Video 3 Demonstration of another frame (StockEZEon), which is helpful for patients who cannot bend down very much

Video 4 Demonstration of the  EasySlide Caran for compression stockings with closed-toe area ( this video has no audio)

Video 5 Demonstration of the  Sigvaris Magnide On Off System for compression stockings with closed toes

Video 6 Demonstration of the Sigvaris Doff N`Donner that has a very different design compared to many of the other aids.  We have tested this, and it is very easy to use. And yes, it is entirely normal to get all sorts of associations when you see this device ;)