Aim: a review of current knowledge and misconceptions regarding the use of compression therapy on the feet.
Misconception: The compression level required for the foot is equal to or greater than that of the ankle.
Discussion: Over the years working with a variety of healthcare professionals from around the world one of the largest misconceptions regarding the use of compression therapy is in regards to the compression applied to the feet. A general misconception exists that the compression level applied to the foot must be equal to or greater than the compression level at the ankle otherwise a swollen foot will result.
For the most part, this misconception has developed from a lack of knowledge of the specific design parameters of “gradient compression stockings”. Typically, stocking manufacturers provide the following information on their label:

1. average compression level at the ankle (i.e. 20-30 mmHg)
2. states whether the garment is gradient or not
3. size

Unfortunately, no other design information is typically provided and as such we have made our conclusions as to how the stocking is actually designed. So the issue becomes our understanding or perhaps more accurately the general misconception of what gradient means in regards to a compression stocking or bandage system.
In regards to gradient compression stockings, existing design standards such as the RAL and ASQUAL, gradiency is required and defined as a decrease in compression level from the ankle to the calf and further to the thigh. The proximal pressure should always be lower than the distal pressure. The specifications even provide the percentage decrease required at each level as we move up the leg. For example a Class II RAL compression stocking gradient profile is:

The current standards are quite explicit in most regards with the exception of any requirement for the compression level for the foot. There is not even a comment that any level of compression is even required for the foot.
And so what has transpired over the years is the general misconception that a compression stocking provides a greater or equal pressure level on the foot versus the ankle in order to maintain gradiency throughout the stocking.
The Facts: A review of designs from the major compression stocking manufacturers around the world revealed that the compression levels currently provided in the foot portion of a stocking is lower than the ankle pressure. While the manufacturers would not provide specific compression design parameters for the foot, on average the design objective is to provide the same general level of compression as is provided in the calf, 50-80% of the ankle pressure.
Additionally Partsch measured compression levels under a RAL Class II elastic stocking utilizing a Pico Press measuring device revealing that the pressures at the dorsal and ventral measuring points of the foot (x position in chart below) are indeed in the same range as the calf measurements. Also of note is that the lateral and medial measurements are significantly higher, an effect of the smaller radius’ associated with the side of the foot. This does bring our attention of the potential for too high a compression level in these areas of the foot and possible detrimental consequences.

So if we apply the RAL gradiency profile for a typical gradient compression stocking with an average ankle compression of 25 mmHg we see that the expected compression levels are from the foot to the thigh are:

We have learned over the years from practical experience and observation that the typical compression “gradient” profile achieved with stockings, compression bandages and adjustable wraps is more than adequate to deal with edema in the foot even though true gradiency is not achieved.
So when making decisions regarding the type compression needed for the foot it is important to keep in mind that the current methods of compression provide a lower compression level to the foot than what we traditional believe.

CircAid’s customer service representatives are often relied upon by patients, therapists and physicians to help decide which compression garment will fit their needs. Our customer service team is dedicated to giving exceptional service and Kathleen Kramer is no exception. Her commitment to the patient, efficient service and her caring attitude is well known among her colleagues and customers.

“My father is elderly, so I understand how he feels when he can’t get the assistance that he needs. When I’m on the phone with a customer, I want to help them find the right product that will help them comply with their prescribed compression therapy,” says Kramer. “I want to get things right the first time, because our products directly affect the quality of their lives.” Kathleen goes above and beyond to help her customers, often following up with them after they have received their garment to ensure that it’s the right fit.

“Juxta-Lite™ is a really great, all-around product for our patients. Whether they have mild to moderate lymphedema, venous disease or another ailment, Juxta-Lite™ is an affordable option. Patients will often express how happy they are to find an affordable option for compression.”

Kathleen is the personification of CircAid’s commitment of making compression easier. Her compassion, strong work ethic, and the pride that she takes in her job embody the dedication of the entire CircAid staff.

Wearing a Comfort CoverUp™ on both arms that match your shirt is a great, lightweight option for disguising your armsleeve.

In addition, wearing a pair of Comfort CoverUps™ on both arms with a sleeveless shirt is a sporty look as well.

To view more accessories for compression garments, visit our webstore: www.circaid.com/store

The top CircAid® Sales Representative for 2010 was, Melissa Coombs. Melissa, a former occupational therapist, services the New England area of the United States and has been working with CircAid® for five years.

When asked how she feels about working as an independent sales rep she stated, “I love the flexibility and variety of my job. It’s never the same day twice! On any given day, I could be in one of six states, talking about anything from compression to wheelchairs.” Melissa is a real asset to the CircAid® team. Her enthusiasm is her one of her signature trademarks, especially in the field. “I love telling people how giraffe skin inspired the CircAid® product line. If they forget everything else I say, they will remember the giraffe skin!”

Melissa exemplifies the caring attitude that is a common thread throughout CircAid®, ” It’s amazing how well people respond to the products. They are so simple and eliminate the obstacles that frustrate the consumers (getting them on) and the medical professionals (compliance). I’ve seen so many dramatic examples of healing and size reduction, it’s hard not to get excited about CircAid®. Rarely does a week go by that I don’t get a call from a therapist, nurse, doctor or fitter telling me about the amazing results their patient had with one of our products! It is fun to promote CircAid® because it can change people’s lives for the better.”

All at CircAid® invite you in congratulating Melissa Coombs for a job well done in 2010 as we look forward to seeing her accomplishments in the coming year.

“I recently returned from my second trip to Nicaragua in the past year, primarily to treat patients with severe venous disease. Our trip was facilitated by a group, Austin Samaritans, based in Austin Texas, and our efforts were all in Matagalpa, which is a city of about a half a million people northeast of Managua. For this trip, my wife, son and I along with three volunteers from Medical City Dallas were on the trip. We tried to see only people with the most severe disease, while those with milder disease were fitted with compression stockings.

“On this last trip, we saw about 30 patients in five days who had open ulcerations on one or both lower extremities secondary to severe venous disease. We also saw another 30, who either had incipient ulceration or severe disease with healed ulcerations. In addition, of course, we saw people with just severe varices and swollen, painful legs. None of these people have ever had treatment before, and, in fact, as they told us they never expected that they would ever have any treatment for their disease.

“On the first trip in 2010, I was frustrated because there were so many severe ulcerations, and I really had no way to treat these after closing the great saphenous [vein] with the laser and injecting the varicose veins. I needed some way to apply compression, and they were not able to put the compression stockings over the open wounds. This is why before my second trip, I contacted CircAid®, and fortunately you were able to respond with a gift of inelastic adjustable compression wraps. I cannot overemphasize the importance of the contribution that was made. One patient I saw on Monday and applied the CircAid® compression garment. When I saw her back a few days later for her laser treatment, she told me that this was the first time in 10 years that she had had any relief from the pain in her leg.

“All of the patients with ulcers had the CircAid® compression garments applied at the end of the procedure and were given thorough instructions on the use. For the first time I felt that I left them with a way to completely treat and bring about healing of the ulcers and relieve the suffering.

“All the people there were so grateful for everything, and your wonderful product was an invaluable addition to our efforts.

“When I left there were several hundred people on our waiting list for our next trip. The need there is so great. Thank you so much.”

This is just one of the ways that CircAid® demonstrates its unwavering dedication to helping make compression easier all around the globe. For more information about this event, contact CircAid® at (800) CIRCAID (247-2243).

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Risky Business

According to the WHO Research Into Global Hazards of Travel (WRIGHT) report, approximately 1 in every 6000 travelers will develop a blood clot. To put that figure in perspective, that would mean as many as 11,000 incidents a year for an airport the size of Heathrow in London.

Immobility associated with long flight durations is a recognized risk factor for developing blood clots, but there are additional risk factors to be aware: previous venous thromboembolism (blood clots); thrombophilia; family history; malignancy; recent surgery; hormone therapy (birth control or estrogen replacement); pregnancy and obesity.

Reduce Your Risk

What can be done to reduce your risks when traveling?

• In-flight Exercise: Walk around as much as possible; do knee bends or rise up on your toes when standing. Additionally flexing your feet periodically when sitting will help increase the blood flow through your legs.
• Hydration: the environment in an airplane will result in dehydration during long flights so be sure to drink plenty of water during your trip. Avoid excessive alcohol as this will also cause dehydration
• Compresion: Graduated compression garments, such as Juxta-Lite™, help promote blood flow in your legs
• In addition if you are at high-risk consult your physician prior to travel and suitable pharmaceuticals may be prescribed to reduce the risk of clotting.

So before your next transatlantic or transcontinental flight take time to think about your risk of developing a blood clot and how you might prepare to prevent it from occurring.

What is DVT?

DVT or Deep Vein Thrombosis is a condition in which a thrombus, or a blood clot, forms in one of the large veins. This clot generally will take place in the leg. This blockage in circulation can cause further health complications such as pulmonary embolisms or even death if not diagnosed and treated effectively. It may seem like an obscure disease; however it may surprise you to know that this condition affects over 2 million Americans each year.

Generating DVT Awareness

If you’re not familiar with the symptoms of DVT, visit www.preventDVT.org to download helpful literature and view a comprehensive symptoms list. Some of the symptoms may include pain, tenderness, edema and/or skin discoloration of the affected limb. Compression therapy plays a major role in both DVT prevention and treatment. Check in with CircAid’s blog this month for more information and helpful tips on DVT.

Help Your Patient make Informed Decisions

Many patients are unaware of the commitment that is involved in maintaining a daily compression routine, especially with elastic sleeves. Most elastic sleeves are difficult to apply without assistance. One patient in Los Angeles, CA said, “It would take me a half an hour to put on my armsleeve every morning.” Patients should be aware of all of their options before committing to a garment. Keeping samples of all available products on site is a great way for patients to get a feel for what they are signing up for. Once the patient can touch, feel, and fully process the tangible realities of the products, it may surprise you what their preference is.

Why Patients are Choosing Juxta-Fit

Patients are widely responding to the new Juxta-Fit™ Armsleeve. It’s Breath-O-Prene® fabric is comfortable, breathable and helps keep the skin dry and fresh. The Juxta-Fit Armsleeve was designed to be pulled on easily, without outside help or assistive devices. The bottom-line is that the new Juxta-Fit™ Armsleeve is so easy for patients, and makes it possible for them to manage their condition while being able to maintain an independent lifestyle. The Juxta-Fit™ Armsleeve is priced competitively with other custom sleeves, and comes with a six month warranty.

The Juxta-Fit™ Armsleeve, Gauntlet, and Glove are now available for order. The measuring chart and order form are available for download by clicking here. Email us for Juxta-Fit™ pricing or call CircAid® Customer Service at (800) CIRCAID (247-2243) for further information.

Important Principles of Bandaging*

Note that the 50% overlap was applied to provide gradient inelastic compression. Bandages are additive meaning that each layer of bandaging adds more compression to the limb. In order for bandages to establish sufficient resting pressures and high working pressures, multiple layers of short-stretch material are needed to create an inelastic compression model. An overlap in bandaging is necessary to keep each turn of the bandage on the limb to provide a lasting compression system.

The Downside to 50% Overlap

Bandaging and compression systems with a 50% overlap often require the patient/practitioner to completely undo and reapply the system to adjust compression levels. With the primary goal of patient compliance, this can often be extremely frustrating. Frustration can turn into an insurmountable obstacle when a patient is faced with additional complications such as decreased lung function, is overweight, or has range of motion or strength challenges among other medical conditions.

The Main Goals

The goal is to achieve the same results as bandaging, not mimic the application method. When examining whether compression garments are following the principles of bandaging, the following items are essential:

• Does the garment provide consistent gradient, inelastic compression? Consistent, inelastic gradient compression is what is effective in the treatment of lymphedema, venous disease, and other forms of edema.
• Does the garment allow for easy adjustment? The main reason for choosing a compression garment over bandaging is for patient compliance. If a garment is just as complicated as bandaging, it defeats the purpose.
• Does the garment accommodate compromised areas of the limb while maintaining gradient compression? If the patient is wearing a garment that doesn’t fit the affected limb, or doesn’t provide adequate compression, the results may not be successful.
• Does the garment prevent unnecessary irritation or harm to compromised skin? If the garment is made from inferior material and frays or disintegrates this can irritate the affected limb.
• Does the garment accommodate reduction/enlargements of the limb? Once the affected limb is exposed to consistent compression, the limb may reduce significantly. If the garment cannot accommodate this reduction, the correct compression may not be applied.

Making Compression Easier

It’s not just a tagline, it’s a philosophy. CircAid is dedicated to helping all patients become more independent. The Juxta-Fit and Juxta-Lite product lines are simple to use, comfortable, sleek, and light-weight. For more information on how CircAid products can help you or your patient become more compliant with their compression treatment, contact us.

*For Further Reading on Bandaging Principles:

• Klose, Guenter. “Lymphedema Bandaging: Practical Bandaging Instruction for Lymphedema Patients and Therapists”. LOHMANN GmbH & Co. 1994
• Klose, Guenter. “Course Manual for Manual Lymph Drainage, Complete Decongestive Therapy Certification Course”. Klose Norton Training & Consulting, LLC. 2000

• How much, if any, compression is effective in healing ulcers?
• How much, if any, compression is effective in reducing ulcer reoccurrence?

How Much Compression is Enough Compression?

In the healthcare industry, it’s been established that 40mmHg, or greater, of compression at the ankle zone is required to heal a venous stasis ulcer. Numerous studies over the years have shown that 70-80% of all venous stasis ulcers have healed with compression therapy alone. There are several avenues of achieving this level of compression during the healing process from paste bandages, multi-layer bandages, short-stretch bandages, multi-layer compression stocking systems, and more recently compression wrap systems such as Juxta-Lite.

My Ulcer is Healed. What Now?

For most, once they are diagnosed with a venous stasis ulcer, they are treated with one of the compression systems available to provide 40 mmHg compression. Once the ulcer is healed, what is the next step? Most are prescribed to wear an elastic stocking in order to maintain a daily compression regimen in the leg. This is in efforts to prevent another venous ulcer from forming in the limb again. Many patients wonder how much compression is necessary for this treatment?

In February 2009, Dr. Dragan Milic provided the answer to this question at the American Venous Forum meeting. Dr. Milic reported the two year follow-up results of over 320 venous stasis ulcer patients that were healed with compression bandaging and then were placed in compression stockings that provided A) an average of 25 mmHg compression at the ankle or B) an average of 40 mmHg compression. 1 out of 4 patients that received stockings that provided 25 mmHg had their ulcers come back during the 2 year period. While those who wore 40 mmHg compression stockings reduced the recurrence by 50%.

Therefore, while wearing a compression garment that provides a lower level of compression may help, if you maintain a daily compression regimen of 40mmHg or more, the chances of an ulcer forming on your leg again are drastically reduced.

Is Something Better than Nothing?

If you have ever had to wear an elastic stocking, you may know why some will opt for a lower level of compression. The answer is simple, compression stockings are very difficult to put on; especially stockings that have higher compression levels (30-40 mmHg and 40-50 mmHg). If you are a healthcare professional that has prescribed a compression stocking, you may be familiar with the fact that many patients, when faced with having to put on higher compression level stocking each day, may become non-compliant. That is why compression wrap systems, such as Juxta-Lite, are growing in popularity. The easy application, assured compression capabilities (levels 20-50mmHg), and durability makes it a good fit as patients no longer have to choose between something easier and something more effective in managing their disease.

For more information about Juxta-Lite, contact us or visit our website.

Compression is one of the most effective treatments for Lymphedema and Venous Disease. However, complying with compression can be a challenge. If find yourself in this situation, you will be interested in the solutions below:

• If you cannot don a compression stocking: The patented Juxta-Lock™ closure system, for Juxta-Fit™ and Juxta-Lite™ compression garments, is specifically engineered for easy application and easy adjustments as needed throughout the day.
• If your limb reduces or enlarges:
  Most of the compression garments produced by CircAid can accommodate up to a 5-20% reduction/expansion without alteration in comfort or effectiveness.
• If you find your compression garment is too uncomfortable for active use: Juxta-Fit™ and Juxta-Lite™ garments are sleek, comfortable and breathable enabling your patient to apply daily compression while maintaining an active and independent lifestyle.
• If you find your compression garment too uncomfortable for nighttime use:
  Graduate™ Leggings and Measure-Up™ Armsleeves feature inelastic bands that tighten around a soft, comfortable foam liner, insuring smooth comfortable compression over the entire limb, which is ideal for night-time or sedentary use. Through the use of “D-rings” and measuring guides, tightening and adjusting to gradient compression levels are easy to achieve.
• If you are looking for a garment that can be used for daytime and nighttime:
  Juxta-Fit™ and Juxta-Lite™ garments are sleek, comfortable and breathable enabling your patient to apply daily inelastic compression while maintaining an active and independent lifestyle. Your patients will not have to sacrifice comfort as they have the flexibility to adjust the compression level to what is comfortable.
• If you cannot fit in a standard size compression garment:
  Custom Juxta-Fit™, Graduate™ and Measure-Up™ garments products can be made to fit the contours of almost any limb. To see examples of larger and unique sized patients who have been fitted into a custom garment, click here.
• If you have to cut off your bandages:
  Patients who are being bandaged for venous stasis ulcers no longer have to make a choice between being compliant with their treatment and maintaining their hygiene. Juxta-Lite™ leggings can be removed to shower, and reapplied afterwards to the prescribed compression level.

These are just a few ways that CircAid is making compression easier for the patient and for the healthcare professional. If you would like more information on using any of CircAid’s compression garments contact CircAid® Customer Service at (800) CIRCAID (247-2243) or visit our website: www.circaid.com.