Night-time Compression

Maree O’Connor, Physiotherapist 

Over the past 4 to 6 years there have been several products launched specifically for night- time. When I first launched into working in the area of lymphoedema, close to 30 years ago, night time compression was usually after an intensive period of bandaging and manual lymphatic drainage. This consisted of self-bandaging or having a carer bandage. The reason was to try and avoid rebound oedema after bandaging. Little did I know that the multilayer bandaging that I performed, that felt hard as a rock to avoid slippage, was delivering a much higher level of compression than the compression garment that I eventually fitted them in after the reduction had been achieved. When clients couldn’t tolerate the ongoing night-time bandaging in the maintenance phase we resorted to old compression garments. As time passed I reduced prescribing night-time compression mainly due to comfort reasons as well as with new bandaging products rebound oedema wasn’t as evident.

An article by Tobias Bertsch sparked my interest in this area.

Bertsch, T. (2018). Evaluation of a novel night-time compression garment: a prospective observational

study. British Journal of Community Nursing, 535 – 541.

In particular, the reflective questions in this article made me question my current management strategies. These are:

Are your lymphoedema patients aware of the importance of night-time compression in managing their condition?

Do your lymphoedema patients consistently use night-time compression?

For your patients who do not use night-time compression consistently, what are the reasons for this lack of therapy adherence?

My clients don’t know the importance of night-time compression as I am not sure I am aware of which clients are optimal for this type of therapy. There is also the issue of cost. With all the new devices there comes an added burden of cost. People who have lymphoedema, that requires compression therapy, already have significant financial burden due to compression garments and therapy I feel I need to be convinced that night-time compression is going to provide a positive outcome on their lymphoedema management to warrant the expense.

Does this sound familiar?

What do we know?

To the best of my knowledge, there are no randomised controlled studies on the efficacy of night-time compression. Some studies are comparative, retrospective or experimental. In some studies, night-time compression is part of several therapies and it is hard to work out which therapy provided which effect. Taking this into consideration it is still useful to review the available studies.

Before reviewing the studies on devices that have been specifically developed for nighttime use a study in 2011 by Stephane Vignes et al considered factors influencing breast cancer-related lymphedema volume after intensive decongestive physiotherapy. It found that compression therapy, combining the wearing of an elastic sleeve during the day and a bandage overnight, represented the main means to stabilize the lymphedema volume during the maintenance phase.

Stephane Vignes, Maria Arrault & Alain Dupuy (2007) Factors associated with increased breast cancer-related lymphedema volume, Acta Oncologica,

In contrast to oedema volume considerations, Ambreen Chohan et al in 2019 investigated the effects of a compression garment on skin tissue oxygenation in healthy individuals.

Examination of the effects of a new compression garment on skin tissue oxygenation in healthy volunteers.

Chohan A1, Haworth L1, Sumner S1, Olivier M1, Birdsall D1, Whitaker J1,2. J Wound Care. 2019 Jul 2;28(7):429-435.

Click to read the abstract

Objective: Compression devices have been shown to reduce venous stasis, increase blood flow and skin tissue oxygenation (StO2), promoting healthy tissue. This study aimed to explore the efficacy of a new compression garment in three different positions in healthy adults.

Methods: In this quantitative study, potential participants were screened and recruited using the Physical Activity Readiness Questionnaire (PAR-Q, Canada). Participants attended three separate, one-hour sessions to evaluate StO2 in supine-lying, chairsitting and long-sitting positions. StO2 was recorded for 20 minutes pre-, during and post- a 20-minute intervention using a compression garment, TributeWrap (Lohmann-Rauscher, Germany). A repeated measures analysis of variance (ANOVA) was followed by post-hoc pairwise comparisons.

Results: A total of 28 healthy volunteers took part (aged 24.6 ±8.4years; 13 males, 15 females). A significant difference was seen between the three positions (p<0.001). Chair-sitting had the lowest StO2 pre-intervention, increasing StO2 significantly (32.25%, p<0.001) during wear of the compression garment (24.8% higher than baseline post-intervention). No significant difference was seen between long sitting and supine-lying (p=1.000). In contrast, long sitting and supine-lying StO2 was higher pre-intervention compared with chair-sitting and only increased post-intervention (11% and 16.8% respectively, p<0.001) compared with baseline. Conclusion: The compression garment significantly increased StO2 levels in both seating positions. Further studies are required to determine if increasing StO2 through short intervention sessions with this device has the potential to improve self-management of tissue health in individuals with reduced mobility, oedema or venous insufficiency. Declaration of interest: The authors have no conflicts of interest. This is an independent research project, however all compression garments were provided by Lohmann-Rauscher for testing.

Below is a link to a Webinar by Justine Whitaker that discusses the results of the TributeWrap concerning the effects on skin oxygenation when there is oedema.

Please note this has been developed for the US market and there is advertising included.

Duration 51.03 minutes

Justine Whitaker (2016) explored the views on lymphoedema management at night from patients across five countries.

Lymphoedema management at night: views from patients across five countries

Justine C Whitaker. British Journal of Community Nursing, Vol 21, No 10, Chronic Oedema October 2016

It was a small cohort of 94 patients and small numbers per country. Several variables may have not been controlled and no information in the paper describes how the oedema was measured and its reliability. The outcomes were only provided as a percentage change. The key points that the author found were:

  • Patients experience a positive effect from using compression for lymphoedema for up to 24 hours.
  • Sixty-six percent of all patients reported oedema during the night was the same or greater than that experienced in the daytime.
  • More than 80% of patients experienced a reduction in or maintenance of their level of lymphoedema when using night-time compression.
  • Patients reported both increased activity and inactivity as triggers for oedema, reinforcing the need for an individual and holistic assessment of the patient when designing a lymphoedema management plan.
  • The top three reasons given for not using night-time compression were fatigue, heat and the oedema being stable.
  • Patients use a variety of products to supplement their night-time compression, from donning aids and pumps to creams and moisturisers
  • Areas for improvement focused on product design improvements; designing a product that did not feel so tight, did not slip or dig in and did not feel so hot to wear. Making applications easier would prove a great benefit as 15% of users currently require assistance to apply the product. As the incidence of lymphoedema increases with age easier means of an application needs to be available.

Lymphoedema management at night: views from patients across five countries – Justine C Whitaker. British Journal of Community Nursing, Vol 21, No 10, Chronic Oedema October 2016

In 2017 a paper on the auto-adjustable Mobiderm night-time compression sleeve was published.

Interest of an auto-adjustable nighttime compression sleeve (MOBIDERM® Autofit) in maintenance phase of upper limb lymphedema: the MARILYN pilot RCT

S. Mestre1,2 & C. Calais1 & G. Gaillard1 & M. Nou1 & M. Pasqualini3 & C. Ben Amor3 & I. Quere1,2,4. Support Care Cancer (2017) 25:2455–2462

The 40 subjects had breast cancer-related lymphoedema and were randomised into either in the night-use group: with MOBIDERM® Autofit (on top of a daytime compression hosiery), or in no night-user group: without MOBIDERM® Autofit (daytime hosiery alone). From Day 31 to Day 90, all patients were fitted with MOBIDERM® Autofit. The primary endpoint was lymphedema volume variation between Day 0 and Day 30. Secondary endpoints were compliance, quality of life (LYMQOL arm questionnaire), functional symptoms(heaviness, limb use limitation, pain), sleep quality, and safety. All subjects had just completed an intensive phase of DLT. The results published were that the volume increase from day 1 to Day 30 was higher in the no night use group and when all subjects were fitted with the Mobiderm autofit from day 30 the volume remained stable in both groups. The device improved functional symptoms and function domain and it was well accepted.

Interest of an auto-adjustable nighttime compression sleeve (MOBIDERM® Autofit) in maintenance phase of upper limb lymphedema: the MARILYN pilot RCT – S. Mestre1,2 & C. Calais1 & G. Gaillard1 & M. Nou1 & M. Pasqualini3 & C. Ben Amor3 & I. Quere1,2,4. Support Care Cancer (2017) 25:2455–2462

This was followed by another paper on this product.

Clinical use of a Night-Time MOBIDERM Garment as a Treatment Modality for Breast Cancer-Related Lymphedema: A Retrospective Longitudinal Cohort Study Toccafondi A1,2, Bonacchi A2, Miccinesi G3, Baroncelli TA1, Franchi G1, Ben Amor C4, Pasqualini M4, and Muraca MG5. Ann Vasc Med Res 4(4): 1061 (2017).

This observational study aimed to investigate the use of a night-time compression sleeve (NTCS) as routine maintenance therapy for breast cancer-related lymphedema (BCRL). There was a retrospective analysis of 145 breast cancer patients who over five years used the Made-to-Measure Mobiderm® NTCS as adjuvant treatment for BCRL. The total sum of the percent differences between the two arms (%) after 6 months of NTCS use was the principal criterion. The circumferences of each patient’s arm at the beginning of the NTCS use (baseline measurement=T0), and data from 6 months before (T-1) and 6 months after (T1) the use of the NTCS were considered.

Data showed a significant collective average decrease of 6.6% of the percent differences among all samples (n=145) between baseline (T0) and T1 (p=.010). Among the newly diagnosed patients, there was a greater significant reduction of 13.4% after 6 months of NTCS use (T1) compared to baseline (p=.013). Among the 74 treated lymphedema patients, the percent differences after NTCS use was stabilized, while in the period before the NTCS use (T-1) and baseline, this percent differences significantly increased by 16.9% (p<.001). The study suggests that the night compressive sleeve is an add-on treatment during the maintenance phase which goal is to extend the results obtained by an intensive phase. Among the patients of this study, this device was prescribed also to patients already on daily treatment and showing an increase in their lymphedema percent differences between the two arms during the 6 months follow-up previous to the introduction of the night garment.

The limitations of this study include that it was retrospective and other objective measures, such as quality of life, weren’t carried out.

Clinical use of a Night-Time MOBIDERM Garment as a Treatment Modality for Breast Cancer-Related Lymphedema: A Retrospective Longitudinal Cohort Study Toccafondi A1,2, Bonacchi A2, Miccinesi G3, Baroncelli TA1, Franchi G1, Ben Amor C4, Pasqualini M4, and Muraca MG5. Ann Vasc Med Res 4(4): 1061 (2017)

The article by Tobias Bertsch, that sparked my interest in this area, was a prospective observational study of 91 patients that wore the JOBST Relax custom made night-time compression garment. The subjects had stage 2 arm or leg lymphoedema. Unlike the previous studies, whose objective measurement was a change in circumference, this study evaluated the views of the subject, via a questionnaire, on the garment’s performance, its safety parameters and their satisfaction with it, and elicited lymphoedema-specific data on their quality of life. They completed a questionnaire before wearing the Relax garment which enquired about the compression garments they had used previously and the duration/type of lymphoedema present. The second measure was after 21 days of wearing the garment.

Performance criteria included fit, wearing comfort, heat, perspiration, quality of sleep, the effect on daytime compression in the morning, patient satisfaction with the garment and lymphoedema specific QoL. Safety criteria included the presence of skin erythema, rash, dryness, itching, unpleasant pressure marks, and pain. Patients also reported wearing times.

Results

Ease of use and comfort – Patients rated the garment’s ease of use and comfort highly. Fit, wearing comfort and breathability were deemed ‘good’ or ‘very good’ by at least 86 patients (94.5%). Appearance, donning and doffing were rated as ‘good’ or ‘very good’ by at least 77 patients (85%).

The sensation of heat and perspiration – Seventy-eight patients (85.7%) and 79 patients (86.8%) rated the night-time compression garment as ‘good’ or ‘very good’ in terms of avoiding heat generation and perspiration, respectively.

Tolerability – The night-time compression garment was associated with a marked reduction in the occurrence of erythema on the skin compared with baseline.

Quality of sleep – Eighty-six patients (94.5%) stated that, compared with what they had experienced before first wearing it, the quality of the sleep associated with the night-time compression garment was ‘very good’/’good’.

Effect on quality of life – The night-time compression garment had a positive impact on disease-specific QoL parameters, compared with baseline. The largest improvement related to the overall effect of lymphoedema on QoL: 49 patients (53.8%) reported that the disease affected them ‘a lot’ or ‘a great deal’ at baseline, compared with 38 patients (41.8%) at the study end.

Overall patient satisfaction – Eighty-six patients (94.5%) rated the night-time compression garment as ‘good’ or ‘very good’.

This study found that the key factor influencing adherence to a night-time compression garment is comfort. This study has several limitations. Patients were recruited after completing decongestive lymphatic therapy and thus constituted a homogenous patient population that was optimally decongested and had limited complications, which positively influenced their QoL

Bertsch, T. (2018). Evaluation of a novel night-time compression garment: a prospective observational study. British Journal of Community Nursing, 535 – 541.

The supplement that accompanies this article includes case studies that explore the use of the JOBST relax for the following indications:

  • Lymphoedema exacerbated by a fall
  • Patient unable to wear a day arm sleeve for work-related reasons
  • Extremely swollen caused by lipo – lymphoedema
  • Breast cancer-related lymphoedema affected by recurrent infections
  • Lower limb lymphoedema that recurred after decongestive lymphatic therapy
  • Lymphoedema in a palliative care setting
  • Breast cancer-related lymphoedema and a painful, pitting arm
  • Strategy for maintaining the effects of decongestive lymphatic therapy
  • Avoiding the need for repeated decongestive lymphatic therapy

Relax in comfort and sleep well – Using night-time compression to avoid recurrent oedema

Finally, the most recent article on this subject was published in April 2020 by Natalie Phillips and Sue Lawrance.

Haddenham Comfiwave:  a unique compression device for lymphoedema treatment. Natalie Phillips, Sue Lawrance. Br J Community Nurs. 2020 Apr 01;25(Sup4):S31-S35.

Read the abstract

Compression therapy is the mainstay of treatment in venous and lymphatic diseases. Optimisation of compression therapy is not a new concept, but, in the UK, the use of 24-hour compression therapy as part of the maintenance phase of treatment has not been standard practice and, until recently, has only been adopted by certain specialist centres. One such modality in the process of optimisation is the use of products that are classed as ‘reduced compression’ or ‘night-time garments’. These are not traditional flat- or circular-knit garments but are made of various components to include foam and, more recently, knitted cotton fabrics. Haddenham Comfiwave is a new product that has recently been brought to market and does not feature in the literature reviewed. Although a new unique product in its own right, it has been demonstrated to fit within the common groups of products discussed.

This explored both the evidence for 24-hour compression but also discussed the outcomes of wearing the newly released Haddenham Comfiwave via three case studies. This device is very different from other night-time compression as its non-traditional flat-knit, highly elastic, uneven, mesh fabric, designed to provide a reduced level of therapeutic compression to the patient. The article states “Comfiwave is composed of a single layer of knitted fabric that delivers therapeutic compression by using highly elastic yarn and highly breathable cotton and is latex-free. Due to the elastic nature, it aims to be easy to apply and is available as an arm, combined arm with a mitten, below knee or full-leg garment”.

The first case study considered lymphoedema with secondary breast cancer disease with neurological changes and soft, pitting of the arm and hand. Wearing the Comfiwave day and night resulted in a marked improvement in her arm and improvement in her hand function. She also wore Pertex Light, flat-knit class 1 glove to manage the very soft dependent hand/finger oedema.  The second case was a 29-year-old lady with Milroys disease since 11 years old. She had completed an intensive period of decongestive therapy which included MLD, IPC bandaging and wraps. This was followed by wearing flat knit garments and Mobiderm alternating with wraps overnight. The client felt that this combination was bulky and hot in summer. She then wore the Comfiwave overnight with the wrap over the top which was more comfortable to wear. Eventually, she only needed the Comfiwave at night. The third case study looked at using Comfiwave to reduce oedema that increased slightly at the end after taking off her compression garment. After 2 weeks the leg had red8uced a further 1-2cm and the tissues were softer.

It is evident that although there is no high-level research into night-time products there are several indications that may warrant this type of compression not only the traditional reason to maintain the effects obtained from complex decongestive therapy. Many factors will influence a client to concord with this type of management especially about product wearability. There is also the possibility of increase skin tissue oxygenation when wearing compression 24 hours per day.

Night-Time Compression Course

To explore the various products and also investigate what practitioners are doing concerning night-time compression a free online course has been developed. This consists of:

Part A: An online module that explores the evidence for night-time compression and various products available for night-time compression.

Part B – An interactive webinar for practitioners to discuss the use of night-time compression both positive and negative and how to choose which of their clients should wear night-time compression taking into consideration cost implications.

When: Thursday, 6th August from 7.30 to 8.30 pm EST

After the webinar, a summary of the outcomes of the webinar will be compiled. Participants will be asked to complete a questionnaire that will be followed by a certificate of completion for both the online module and participation in the webinar.

Register for this course here