ORTHOTIC DEVICES AND THE LYMPHATIC CIRCULATORY SYSTEM
The lymphatic system is part of the circulatory system and it is indispensable for life. In physiological conditions, the main functions assigned to the lymphatic system are the maintenance of interstitial fluid homeostasis, immune surveillance, and the absorption of dietary fat in the intestine. Morphological or functional changes in lymphatic vessels can contribute to disorders such as lymphedema, tumor metastasis, inflammation, and other pathological conditions. Lymphedema, either congenital or acquired, is characterized by disruption of lymphatic flow (Organic Impairment), leading to the chronic and progressive buildup of lymphatic fluid.
Lymphedema is a chronic condition requiring long-term treatment to control its progression. Management of limb swelling, regardless of its cause, requires specialized treatment aimed at effectively and safely reducing localised swelling, including a period of intensive therapy (Phase I), with Complete Decongestive Therapy (CDT), and the use of compression bandages and hosiery prescribed for the long-term management (Phase II) of lymphoedema. Read more about what is the best treatment option for Lymphedema HERE.
Compression garments are used once the swelling has reduced and been stabilized. The compression orthosis helps support, controll and prevent severity of stasis overload, dermal complications, limb contour deformity (disfigurment), pain, decreased peripheral sensation, swelling comorbility, and thus a means necessary to help carry out activities of daily living (ADLs). Without compression devices, the disease progresses and worsens.Compression garments provide graduated pressure to help reduce the swelling associated with lymphedema, reducing the pooling of lymph and moving excess fluid out of the affected area to improve lymphatic circulation.
ORTHOTIC DEVICES IN THE TREATMENT OF LYMPHATIC DYSFUNCTION
Compression garments have been utilized for medical reasons for many years. Orthotic Compression garments are individually designed and manufactured for a particular part of the body, they include stockings, sleeves, hand gloves, toe-caps, face masks, body suits, etc, which are utilized in the areas of lymphedema, venous insufficiency, and lipedema management.
Studies have shown the efficacy of compression garments (Orthotic Devices) in reducing and maintaining lymphedema of the arm and leg, and the importance of long-term compression therapy in lymphedema has been clearly demonstrated. It has also been demonstrated that lymphedema in the untreated limb increased faster in volume than lymphedema that was treated by lymphatic therapy and compression garments. Early treatment (Preventive Medicine) is critical if the long-term complications resulting from poor management are to be avoided.
Orthopedic Compression Garments are a medical nesesity. It is crucial to take into consideration the significant role that compression plays in managing and preventing complications associated with lympahtic impairment. The compression orthosis for lymphedema does not have a mechanical support function, but is to facilitate the function of an impaired body structure (Organic Impairment).
TECHNICAL ASPECTS OF ORTHOTIC DEVICES
Regarding the types of yarn specially indicated for lymphedema, the custom-made flat knit thicker yarn produces stiffer and thicker material that is better at bridging skin folds and is less likely to cut into the skin or cause a tourniquet effect. The finer finish ready-to-wear circular-knit garments may make them more cosmetically acceptable, but it also makes the garments more likely to roll at the top and cut into the limb, causing pain, skin damage, and a tourniquet effect particularly if worn for extended periods.
A basic distinction is made between circular-knitted and flat-knitted compression garments:
- Circular-knitted compression garments (seamless) are mainly used for venous malformations. They are highly stretchable (stockings with elastic fibers) and normally have a lower working pressure than flat-knitted compression stockings.
- Flat-knitted compression garments (slightly harder and with a seam) are mainly used for lymphatic malformations. Their advantage is their good individual adaptability to variable body shapes. The material has very little stretch (stockings without elastic fibers) and has a higher working pressure on the tissue.
When lymphedema is present in the more distal parts of the limbs, the best option is a tailored two-piece custom-made garment with a separate arm/hand (glove) or foot/toe (toe cap), for these make the garments much easier to put on, and increase wearing comfort and compression accuracy.
Compression garments for large extremities or difficult situations (buttocks, breasts, genitals, etc) are usually made in flat-knit fabric, they require a perfect fit and may need the incorporation of a fitted compression pad at a certain location. The material of the compression garment should fit the individual body contours as closely as possible and not cause locally increased pressure or skin irritation when worn.
THE MEDICAL PRESCRIPTION OF ORTHOTIC DEVICES
From a medical point of view, wearing a compression garment is indicated for almost all patients with venous and lymphatic malformations. Chronic lymphedema is an indication for individually tailored compression garments for edema control, while at the same time reducing pain and the feeling of heaviness and pressure, both in the lower and upper extremities. The costs of insufficient or inadequate compression, exceed the costs of adequate compression therapy in the long term because of complications and deterioration of the clinical picture.
It is especially important for patients to wear compression garments when they need to spend long periods of time without being able to move either standing or sitting, or when the body is subjected to heavy physical strain. In practice, for most patients with upper and lower limb lymphoedema it is usually sufficient to wear compression garments only during the day, however, others may also need compression at night.
In terms of treatment of the more distal parts of the limbs, it should be borne in mind that without a glove, the hand and fingers may swell causing reduced independence and loss of dexterity. Also, if toe caps are not fitted, the toes may swell further, leading to skin breakdown can occur, further loss of mobility of the toes and feet. In some cases at the foot level, orthopaedic footwear may also be necessary.
Individual customized Orthotic devices are indicated in patients who have asymmetric or abnormally configured limbs, as these tailored products achieve an optimal, homogeneous compression effect on each individual area, better adaptation and wearing comfort, and reduced skin damage at sensitive areas.
Regarding the prescription of Orthotic Devices, from a medical point of view the compression effect of even a very good compression material decreases after 6 months. The use of compression during the day is essential, and patients who have to apply compression permanently must be able to change their compression garment for hygienic reasons in order to be able to wash it. In the case of children, their continuous growth in body length requires short-term size changes. There are some concomitant diseases and contraindications for compression, which patients should discuss in detail with their physician.
The alternative to compression orthoses by daily use of standard bandages for long-term management is not practical in most cases, as bandages tend to loosen and slip off when undertaking work that requires continuous physical activity, and likewise, dirty bandages can also be an important source of infection.
ORTHOTIC DEVICES IN THE IMPROVEMENT OF PSYCHOSOCIAL FACTORS
Studies demonstrate that impairments impact on both the physical and psychosocial well-being of people with disabilities. Nontreatment or undertreatment are among the principal causes of barriers experienced by patients related to difficulties with social exclusion and inclusion, discrimination, access to adapted employment, and an optimal Quality of Life.
Due to the progressive nature of lymphoedema, patients who are untreated or undertreated may experience, due to the disease progression, a sense of hopelessness which is related to their consequent inability to participate fully in major life areas such as education, work, or community activities. Some may express sadness at not being able to work to support their family and are disappointed that they need to depend on others for support. This sense of hopelessness usually improves substantially when they have access to adequate treatment options. Read more about the Psychological Distress associated with Nontreatment or Undertreatment of Lymphedema HERE.
Access to adequate treatment and assistive devices is reflected at the most basic level by an improved ability to use the affected limbs. These are identified as facilitators for mobility and daily functioning, and inclusion facilitators which positively affect the participation in social activities, and may also help to improve a person's sense of self-worth and the possibility to lead a positive, happy, and fulfilled life.
ORTHOTIC DEVICES IN THE FRAMEWORK OF DISABILITY AND INCAPACITY RECOGNITION
Many people depend on assistive devices to enable them to carry out daily activities and participate actively and productively in the community. Lymphedema requires the permanent and continuous use of compression in order to be able to ambulate or undertake different tasks. This should be taken into consideration in the medical examination used for the recognition of disability or incapacity for work by the Social Security. Likewise when the person’s impairment progresses and worsens without the orthotic device, this should also be part of the report. Read more about Lymphedema and Disability HERE.
There are individuals who, while requiring the permanent use of compression garments, have difficulty with the device in place or are unable to use it, and the medical professional should document the medical reasons for this. Issues related to limitations in wearing an Orthotic Device, such as heat, sweating, discomfort when sitting, kneeling, or those resulting from the continuous and permanent use of compression orthoses, should be taken into consideration at disability or incapacity for work recognition level.
There may be restrictions in specific occupations due to wearing compression garments, and people can be worse off in terms of work performance and career. Orthotic Devices can cause difficulties with jobs involved in precision work with hands and fingers of the affected limb, and likewise certain restrictions regarding lower limb compression. There can also be disadvantages or discrimination to accessing certain jobs because of the visible Orthotic Device. The permanent use of Compression devices can negatively condition and not allow an active working life under the same conditions as a healthy or non-disabled person.
