Medical compression stocking

The medical compression stocking (MKS) is a compression stocking which , as a medical aid in compression therapy, causes the vessels to constrict using defined pressure . The resulting improved blood flow in the extremities is the basis for the therapy of varicose veins , leg vein thrombosis , chronic venous insufficiency and post-thrombotic syndrome . In addition, foot and mouth disease is used to guarantee the therapeutic results of manual lymphatic drainage in patients with lymphedema and lipedema . The compression therapy has a reflux-promoting effect that extends into the deep vessels, enables waste and waste products to be removed and reduces edema. The latter also leads to a reduction in pain and volume in the legs, which means relief for the patient in several ways. However, only half of the medical compression stockings prescribed in Germany are actually worn.

material

In contrast to other materials used in compression therapy , such as short-stretch bandages , adaptive bandages or intermittent pneumatic compression , medical compression stockings are suitable for long-term or permanent treatment of people with venous or lymphatic diseases. It is a form of therapy that has a lasting effect on the quality of life of those affected, often for a lifetime. Therefore, medical compression stockings are now available in numerous colors and with a large number of patterns - so it is possible to adapt the respective care to the individual clothing style of the person concerned.

Compression classes

The pressure that medical compression stockings exert on the respective leg is based on the patient's state of health and is divided into compression classes ("CCL", "Ccl" or "KKL") I-IV.

Compression stockings. Wrinkles like here on the left leg (in the picture: right) should be avoided.

Compression classes
KKL	intensity	Pressure in mmHg	in KPa
I.	light	18-21	2.4-2.8
II	medium	23-32	3.1-4.3
III	strong	34-46	4.5-6.1
IV	very strong	49 and larger	at least 6.5

There are various international standards, the table above corresponds to the standard RAL-GZ 387, which has become established in Central European countries, with the exception of France. The specified pressure ranges refer to the basic pressure that is exerted on the ankle - more precisely: measuring point "B"; towards the heart (upwards) the pressure decreases. Hosiery models from different manufacturers can differ significantly from one another within a compression class. This is all the more true since relative ranges apply to the other measuring points, which refer to the base value. So z. B. the pressure at measuring point "B1" corresponds to between 70 and 100% of the base pressure (at measuring point "B"). The compression classes only describe the so-called resting pressure that is exerted on the tissue when it is at rest, i.e. when lying down.

For those affected who are unable to put on a medical compression stocking with a high KKL for physical reasons, such as lack of mobility or low physical strength, the prescription of two medical compression stockings with a lower KKL is possible. If these are pulled over each other, the compression classes add up. Another way of caring for these patients is to prescribe individual components such as forefoot cap, stockings and capri / cycling shorts.

Medical compression stockings are used in the second phase of compression therapy. In this phase, the extremity is already largely unblocked by compression bandages or adaptive compression bandages and it is a matter of maintaining this condition with an adapted compression stocking. Compression stockings and compression bandages serve as an abutment for muscle movement , much like a muscle fascia , increasing their effectiveness and thus the return of blood from the legs to the heart. Thus, compression can only have an effect in maintenance therapy if the wearer of the compression stocking moves sufficiently. Compression stockings can only be of limited effectiveness for immobile people and their use is supplemented , for example, by intermittent pneumatic compression . To ensure undisturbed arterial blood flow, the ankle-arm pressure index (KADI) is determined with a pocket Doppler when prescribing medical compression stockings. The KADI should be above 0.6. Compression therapy is only used to a limited extent in patients with peripheral arterial occlusive disease and polyneuropathy . Medical compression stockings are now also being offered specifically for this group of patients - such products have a low resting pressure (e.g. KKL I) and a high working pressure (e.g. similar to KKL III).

Further material properties

In addition to the strength of the compression pressure, there are other parameters that are not part of the standard, but can be relevant for the effect of the compression. In recent years, the importance of stiffness (or strength ; English stiffness or slope ; the English term stiffness is also often used in German literature) of the material has gained in importance. This is described more precisely by pressure-strain curves. Material with high stiffness is stronger, more stable on the wall, shorter-stretching and less elastic (less stretchable) than material with lower stiffness. With the same compression class (i.e. with the same resting pressure), stockings of higher stiffness offer higher working pressure . This is generated when moving (walking) through muscle tension. The expansion of the muscles to the outside is prevented by the greater wall stability of the stocking, so that the "massage effect" is increased in the depth of the tissue. Conversely, if the stocking is more flexible, the muscles have more leeway to expand outwards, which means less depth effect. High working pressure is important in compression therapy, as its effectiveness is significantly increased by movement. Since the stiffness is currently not part of the norm for medical compression stockings and is therefore not specified by the manufacturers, the degree of stiffness is not obvious to the user when a special stocking is selected. Expert advice is therefore important. There is also another parameter, bending stiffness ; high flexural rigidity makes it difficult to slide into folds of tissue. High material strength is particularly relevant and usually advantageous for compression therapy for edema patients.

production

Medical compression stockings are made of natural cotton or synthetic materials such as microfiber , polyamide or polyester . These fibers wrap around a core made of artificial elastane , or - more rarely - natural rubber , which gives the stocking fabric its elasticity. The core of the weft thread is significantly thicker than that of the warp thread . The elasticity of the medical compression stocking is therefore primarily determined by the core of the weft thread, while all other components have only a marginal influence. The production is basically based on two different knitting processes: circular or flat knitting.

Circular knitting process

Circular knitted medical compression stockings

Circular knitted medical compression stockings are manufactured on a cylinder with a defined number of knitting needles. This creates a seamless stocking, the fit of which, however, due to the specified number of stitches, cannot be variably adapted to every possible difference in circumference. For this reason, compression stockings were only produced using the flat knitting process until the 1950s. Only the technical development in the course of the introduction of the feeder ( French: supplier ) made it possible to regulate the thread tension in the manufacturing process, so that the knitted fabric can now be pulled together more tightly in the ankle region than on the wider calf. Since then, it has been possible to slightly adjust the circular knitted products with additional or smaller stitches, but for patients with considerable leg circumferences or large differences between the circumference of individual areas, a supply of circular knitted compression stockings is not suitable.

Flat knitting process

Flat knitted compression stockings with seam

Flat-knitted compression stockings are made as lengths of fabric, whereby it is possible to vary the number of knitting needles and thus adapt the product to extraordinary differences in the circumference of the extremities. The final stitching creates a seam along the calf . Flat-knitted medical compression stockings are exclusively made to measure and, due to their material properties, are primarily used in the care of people with lymph or lipedema , but also for severe venous disorders with a tendency to edema. In contrast to circular-knitted medical compression stockings, the material of these products is coarser, but also stronger and thicker. Flat-knitted models are also less elastic, so they are more rigid. Some materials are characterized by a coarser structure that allows greater air permeability and supports microcirculation. This achieves a much higher therapeutic benefit compared to the circular knitting process. Since they are significantly more expensive than circular-knitted stockings and also have a reputation for being less aesthetically pleasing and less comfortable to wear, flat-knitted medical compression stockings are less popular than circular-knitted medical compression stockings and have a market share of only 10% (2013). For the indication it says in the list of aids:

"Flat-knitted compression stockings in made-to-measure production are required if neither series production nor round-knitted compression stockings in made-to-measure production allow a fitting due to the indication or the leg shape and the individual structural conditions, or if a higher stiffness of the knit is required."

The guideline makes the following recommendation:

"Because of the type of knitting, flat-knitted MCS usually have a higher stiffness but also a higher flexural rigidity. These properties should be used in the care of patients with lymph or lipedema, severe chronic venous insufficiency (CVI), obesity, but also neuropathies and arterial diseases Occlusive disease to avoid pressure peaks through constrictions can be used. "

Executions

Compression stockings are now available in many standard and trendy colors; Circular knitted models with a slight compression are often hardly distinguishable from nylon stockings in terms of their transparency; with greater compression and with flat knitting, the stockings are usually opaque.

Medical compression stockings are available in different lengths. For the legs, the most common designs are calf stockings (AD), thigh stockings (AG) and tights (AT) (for both sexes; also maternity tights), but also half-thigh stockings (AF). The versions beginning with "A" are optionally available with toe opening (open toe) or without toe opening (closed toe), as well as (flat knit) with toe cap in which the toes are individually in compression. Flat-knitted MKS can be made to measure in many other lengths. They are also available as capri pants, cycling shorts and leggings.

Flat knitted medical compression tights with knee function zones

Flat-knitted MCS can be equipped with many additives, e.g. B. with a knee function zone that prevents constriction in the knee bend and tension on the kneecap, which ensures greater comfort, especially when moving and sitting.

There are also medical compression stockings for arms and hands, as the upper limbs can also be affected by diseases (e.g. lymphedema after surgery or chemotherapy, or lipedema) that require compression. These compressive arm socks and gloves are mostly flat knitted. If the hands or fingers are also affected by edema, the arm socks can be offered with integrated or separate gloves.

Use in various clinical pictures

Medical compression stockings are used for various clinical pictures, the symptoms of which can be reduced or eliminated through consistent and adapted external pressure on the vessels as part of compression therapy. The selection of stockings in terms of compression class and material is based on the clinical picture. A further orientation are the individual characteristics of the person affected, for example, if there is a strong tendency to edema, a flat-knitted medical compression stocking is preferable, while in the case of minor edema - regardless of the clinical picture - round-knitted medical compression stockings with low compression can be sufficient.

Chronic venous insufficiency

The majority of the prescribed medical compression stockings are used in patients with chronic venous insufficiency (CVI) . In this clinical picture, the blood vessels in the legs have widened, so that the return of blood in the direction of the heart is disturbed or no longer guaranteed. The veins narrow as a result of external pressure that is applied to the affected leg as part of compression therapy. This enables the so-called venous valves , which act like backflow valves in the bloodstream, to resume their function. In addition, the speed of blood flow accelerates and edema decreases. The reduction in leg edema leads to a reduction in pain and an approximate restoration of the original leg circumference. The adaptation of the medical compression stockings only takes place after the edema has been reduced by bandages with short-stretch bandages or adaptive compression bandages and thus only begins in the so-called maintenance phase . The positive effect of KKL 2 stockings has been well documented for the therapy of CVI and is associated with a reduction in the associated clinical symptoms.

Post-thrombotic syndrome

The term post-thrombotic syndrome (PTS) , the different, partly related consequences of thrombosis of the deep veins of the legs together (DVT). Clinically, the spectrum ranges from a discrete tendency to swell without any major discomfort to a circular leg ulcer with the most serious symptoms of the disease and serious personal and social problems. Post-thrombotic syndrome is the most important and most serious venous circulatory disorder, affecting around 1% of the population. A clinically recognizable post-thrombotic syndrome develops in 20–50% of thrombosis patients, and in 5–10% in severe form. Compression therapy with medical compression stockings can help prevent the risk of developing PTS following deep vein thrombosis. If a corresponding stocking in high KKL is started immediately upon diagnosis, and the medical compression stockings are worn for at least two years, the risk of developing a post-thrombotic syndrome can be halved. In symptomatic, severe PTS, compression therapy should be continued for life, including to prevent recurrence of DVT. Compression therapy is the basis of the treatment of chronic venous congestion of any origin and is of paramount importance in post-thrombotic syndrome. It leads to a reduction in edema, a decrease in venous blood volume, a reduction in venous refluxes, an increase in blood flow velocity and thus a prophylaxis of recurrent thrombosis. Exercise therapy supports compression therapy decisively, because it activates and optimizes the peripheral vein pumps. Compression stockings KKL II or III with high strength are recommended, depending on the severity and shape of the leg in round or flat knit.

Lymphedema

The swellings that accompany lymphedema are treated with complex physical decongestive therapy . Medical compression stockings are used as part of this KPE. Following the successful manual lymphatic drainage , these products guarantee the sustainability of the congestion success achieved. If lymphedema begins up to stage 1 , medical compression stockings of KKL II are provided. From stage 3, KKL IV stockings are used. People with lymphedema are mostly supplied with flat-knitted medical compression stockings, which can be adapted accordingly to the considerable differences in the circumference of the extremities that occur in this clinical picture. In addition, such products ensure better pressure distribution in such cases than circular knitted models. The medical compression stocking is only used when the affected extremity is decongested as much as possible. The transition phase from supplying compression bandages or adaptive bandages to supplying medical compression stockings is designed individually, as edema can quickly develop again after the compression is removed once at night, or if the application is delayed long after getting up. The medical compression stocking is therefore only measured, adjusted and delivered when a stable condition has been reached. In contrast to compression therapy as part of the therapy of venous leg ulcers, patients with lymphedema can take off the compression stocking during the nightly rest phase to protect and care for the skin.

Lipedema

When lipoedema it is not primarily an accumulation of fluid in the tissue, but a usually hereditary assessed Fettverteilungs- and fat developmental disorder. The affected tissue reacts strongly to pressure pain and also has a slight tendency to develop hematomas. Lipedema occurs almost exclusively in women and its spread is often underestimated due to a lack of adequate diagnostics - according to studies, around 10% of women in Germany are affected by moderately to significantly pronounced lipedema. Lipedema usually occurs symmetrically to the left and right and can only affect the legs or arms, or both. In the early stages, therapy with circular-knitted medical compression stockings of high strength may be sufficient. In the later stages, flat-knitted compression materials with high strength are usually recommended to avoid constrictions. As with lymphedema, compression stockings are only part of the complex physical decongestion therapy , and the compression garments are only adapted to extremities that have been decongested by manual lymphatic drainage . Wearing medical compression stockings helps to maintain decongestion as much as possible and to prevent swelling. In addition, wearing the compression leads to pain relief. The compression should usually be worn during the day from getting up to going to bed.

Tabular overview

The following table is an overview of practical recommendations with regard to the selection of compression stocking therapy for the legs for various indications.

Practical recommendations for compression therapy
indication	KKL	strength	Knitting type
Edema in pregnancy	I-II	low	Circular knit
after variceal surgery	II	medium	Circular knit
Varicose veins without complications	II	low / medium	Circular knit
Thrombophlebitis, thrombosis	II	medium high	Circular knit
(compensated) PAD & CVI	I-II	high	Round or flat knit
post-thrombotic syndrome	II-III	high	Round or flat knit, depending on of severity and leg shape
Lymphedema	II-IV	high	Round or flat knit, depending on of stage and leg shape
Lipedema	II	high	Round or flat knit
Leg ulcer	II-III	high	Ulcer KS, round or flat knit, depending. of leg shape

application

In everyday practice, it is found that some patients seem ashamed of their medical compression stockings and are under the impression of being socially excluded. As an alternative to conventional models, manufacturers have been offering a wide range of fashionable and aesthetic variants of colors, patterns and ornaments for several years, which make it easier for younger people in particular to stand by their compression clothing in public.

Older people in particular, or those affected who cannot easily reach their feet, can benefit from putting on and taking off aids. These are aids that facilitate the handling of medical compression stockings and at the same time protect the stocking material, which can be damaged by fingernails or strong tugging. There are products that either make it easier to put on or take off medical compression stockings, or those that are suitable for both.

Frame for putting on and taking off medical compression stockings

In Germany these aids can be prescribed at the expense of the health insurance companies . The decision for a suitable product is based on adequate information from therapists and providers as well as advice from specialist retailers. There are basically two types of donning and doffing aids:

Racks

These products are often made of metal and can make it easier to put on and take off medical compression stockings. In the case of frames made of metal, the stocking is pulled over the semi-circular rods of the frame so that the person concerned can slip into the open stocking without using his hands. With frames made of plastic, the stocking is pulled over a semicircular shell. Many frames have extendable side arms that can be individually adjusted to the patient's mobility. When the foot is in the stocking, the user grips the side arms and pulls the frame up along the calf until the stocking lies completely on the leg. To take off the stocking, the calf is placed in the semicircle of the frame, then the upper edge of the stocking is folded over and then the leg is pulled up out of the stocking.

Glider

Glider with eyelets and rod, including a sliding sock

The gliders, which are available in many variants, are made of synthetic fibers with high gliding properties. The simplest form of glider are short glide socks, which are often provided by the manufacturer with the prescribed medical compression stockings. Such forefoot sliding aids cover the toes and extend to the heel to make it easier to put on the medical compression stocking in this area. Longer sliding socks reach over the ankles and can also make it easier to take off the stockings by pulling them over the stocking, then folding the upper edge over the sliding sock and pulling both together from the leg. Sliding socks and forefoot sliding aids have a tab or tongue in the toe area so that they can be gripped and pulled out from under the sock. These gliders are only suitable for handling medical compression stockings with an open tip.

Models that also make it easier to put on stockings with a closed toe are more complex. Many products consist of a sheet of slippery material that is placed around the foot and lower leg and then closed to form a tube with a flexible rod and eyelets or magnets. The medical compression stocking is pulled over it. As soon as the stocking is in contact with the leg, the donning aid can be pulled out from underneath, whereby the fasteners are released under tension. Another variant for putting on closed medical compression stockings consists of a longer, narrow strip of material that is clamped between the first and second toes and then guided up under the sole and along the calf. In these models, the stocking slips primarily in these areas and less on the instep and shin .

Gloves

Gloves for putting on MCS, next to them a sliding sock

Some manufacturers of medical compression stockings offer special gloves that are designed to make handling the products easier and to protect the stocking material. For example, when putting on flat-knitted tights with a high compression class, they are almost indispensable. A common variant is the knobbed rubber glove, which is similar to household gloves that are also available in department stores.

Other models consist of an elastic cotton blend with rubberized fingers and palms and are similar in structure to common work gloves from the hardware store. In contrast to donning and doffing aids, gloves are non-refundable.

Material care

Compression stockings should be washed daily, but at least every other day. This extends the life of the compression stockings. As a rule, most models can be machine washed on a gentle cycle at 40 ° without any loss of quality. Please note the manufacturer's instructions on the label of the stocking. For reasons of cost, many users opt for the more economical hand wash. In order to protect the material, medical compression stockings are only cleaned with mild detergent or special stocking detergent. Substances such as plasticizers , which are contained in fabric softeners but also in hair shampoo, impair the material properties of the stockings. Heavy-duty detergents, solvents or even chemical cleaning cause lasting damage to the material and should therefore also not be used. Some products can be tumble dried, but it is generally recommended that the wet stockings be dried flat on a terry towel that is on a clothes horse . The stockings must not be hanging or dried on the heater and not wrung out, kneaded, rubbed or ironed . Proper care of medical compression stockings makes a significant contribution to guaranteeing the therapy-relevant material properties for as long as possible.

When used and cared for properly, medical compression stockings can be used for up to six months before they lose their therapeutic effect. In Germany, therefore, a new prescription is made every six months by the attending physician.

Web links

• Medical compression therapy AWMF guideline of the German Society for Phlebology
• Patient and relatives brochure "Compression Therapy " (pdf) from the Wound Center Hamburg
• Patient information on medical compression stockings from the Vein Center of the Bochum Clinic

literature

• Kerstin Protz, Knut Kröger, Joachim Dissemond: Compression therapy an overview for practice. Springer Verlag, Munich 2016, ISBN 978-3-662-49743-2
• Stefanie Reich-Schupke , Markus Stücker (Ed.): Modern Compression Therapy - A Practical Guide : Viavital Verlag, Cologne 2013, ISBN 978-3-934371-50-7
• Volker Wienert , Markward Marshall: The medical compression stocking. bookwise, Munich 2014.

Notes and individual references

1. ↑ ^{a b c} Protz et al. (2016), page 24
2. ↑ ^{a b} Kerstin Protz: "Compression made to measure" in health professions Das Pflegemagazin, 2012, 64 (7-8) ISSN 0017-9604, pages 36-39
3. ↑ Kerstin Protz: "Modern wound care, practical knowledge, standards and documentation" , 9th edition, Elsevier Verlag, Munich 2019, ISBN 978-3-437-27886-0 , pages 148-149
4. ↑ ^{a b c} Guideline: Medical compression therapy of the extremities with medical compression stockings (MKS) ... German Society for Phlebology , December 31, 2018, accessed on July 16, 2019 . 
5. ↑ CPM van der Wegen-Franken, P Mulder, B Tank, HAM Neumann: Variation in the dynamic stiffness index of different types of medical elastic compression stockings . In: Phlebology: The Journal of Venous Disease . tape 23 , no. 2 , April 2008, ISSN  0268-3555 , p. 77-84 , doi : 10.1258 / phleb.2007.006018 ( sagepub.com [accessed July 21, 2019]).
6. ↑ Kerstin Protz, Joachim Dissemond, Knut Kröger: Compression therapy An overview for the practice. Springer Verlag, Berlin a. a. 2016, p. 102
7. ↑ Reich-Schupke et al. (2013), page 40.
8. ↑ Reich-Schupke et al. (2013), pages 30-32.
9. ↑ ^{a b c} Stefanie Reich-Schupke , Markus Stücker : "Modern Compression Therapy A Practical Guide" , Viavital Verlag, Cologne 2013, ISBN 978-3-934371-50-7 , pages 16-22
10. ↑ Reich-Schupke et al. (2013), page 107.
11. ↑ ^{a b} Günther Bringezu, Otto Schreiner (Ed.): Textbook of Entauungstherapie. 4th edition. Springer-Verlag, Berlin Heidelberg 2014, ISBN 978-3-642-54921-2 , p. 190 .
12. ↑ List of resources of the National Association of Statutory Health Insurance Funds -. Retrieved July 20, 2019 . 
13. ↑ Volker Wienert , Markward Marshall : The medical compression stocking. A systematic overview , bookwise, Munich 2014, pages 71–73
14. ↑ ^{a b c} Nüllen, Helmut ,, Noppeney, Thomas ,, Diehm, C., (Ed.): VTE - Venous thromboembolism . Springer-Verlag, Berlin Heidelberg 2014, ISBN 978-3-642-21496-7 , p. 389 .
15. ↑ Volker Wienert, Markward Marshall: The medical compression stocking. A systematic overview , bookwise, Munich 2014, page 84
16. ↑ Reich-Schupke et al. (2013), page 106.
17. ↑ ^{a b c} Nüllen, Helmut ,, Noppeney, Thomas ,, Diehm, C., (Ed.): VTE - Venous thromboembolism . Springer-Verlag, Berlin Heidelberg 2014, ISBN 978-3-642-21496-7 , pp. 392 .
18. ↑ ^{a b} Reich-Schupke et al. (2013), page 82.
19. ↑ Ulrich Herpertz: "Edema and Lymph Drainage Diagnosis and Therapy Textbook of Oedematology ", 5th edition, Schattauer, Stuttgart 2014, ISBN 978-3-7945-2912-4 , pages 307-310
20. ↑ Volker Wienert , Markward Marshall: "The medical compression stocking, a systematic overview ", bookwise, Munich 2014, pages 105-107
21. ↑ Kerstin Protz, Knut Kröger, Joachim Dissemond: "Compression Therapy An Overview for Practice ", Springer Verlag, Heidelberg 2016, ISBN 978-3-662-49743-2 , pages 94-95
22. ↑ ^{a b c} Reich-Schupke et al. (2013), page 125.
23. ↑ C. Schwahn-Schreiber, M. Marshall: Prevalence of lipedema in working women in Germany . In: Phlebology . tape 40 , no. 03 , 2011, ISSN  0939-978X , p. 127-134 ( thieme-connect.com [accessed June 25, 2019]).
24. ↑ Knut Kröger, Kerstin Protz, Joachim Dissemond, Axel Kramer: Living with a compressive stocking supply , Vasomed The specialist journal for vascular diseases, Volume 29, 20, 2017, ISSN  0942-1181 , pages 65–72
25. ↑ Lipedema fashion. Life with compression. Caroline Sprott's blog, accessed June 10, 2019 . 
26. ↑ ^{a b} Stefanie Reich-Schupke, Markus Stücker (ed.): Modern Compression Therapy A Practical Guide , Viavital Verlag, Cologne 2013, ISBN 978-3-934371-50-7 , pages 164–169
27. ↑ ^{a b} Günther Bringezu, Otto Schreiner (Ed.): Textbook of Entauungstherapie . 4th edition. Springer-Verlag, Berlin Heidelberg 2014, ISBN 978-3-642-54921-2 , p. 192 .

This article is about a health issue. It is not used for self-diagnosis and does not replace a diagnosis by a doctor. Please note the information on health issues !