Ready-Made Versus Custom Compression Sleeves
Compression garments are manufactured using either a flat-knit or circular knit weave. Most ready-made sleeves are seamless circular knit while most custom sleeves are seamed and flat knit. There are many aspects that are shared between these two techniques and fewer that differentiate them.
It must first be stated that there are no good studies that show an advantage to the use of a flat knit vs circular knit compression sleeve. By a good study we mean that there are sufficient people enrolled, it is run by people who do not have an obvious bias, the measurements used are valid and the statistics are good.
The term most heard in separating circular knit from flat knit is “containment.” This is not a medical term but generally implies that flat-knit is stiffer and therefore can “bridge” fat folds while circular knit tends to follow the skin into the folds. However, there is no research showing any clinical advantage of one type over the other. The other discussion point used is that flat-knit, with its heavier fabric, is more like a short stretch bandage and performs a pumping action when worn. Unfortunately, this is a misconception. While the flat-knit is thicker, it is not like a short stretch bandage and the compression profile is similar to that of a circular knit.
THE THREE “CS”: COMPRESSION, COMPLIANCE AND COST.
In ready-made sleeves, the compression is usually stated as a compression class such as class I, and as a range of compression, such as 20-30 mmHg. Manufacturers also give a range of sizes for 3 or more points along the arm. For instance, a medium size compression class 1 sleeve should have a wrist measurement between 16.5cm and 21.5 cm. What this means is that at the wrist, where the pressure is at the highest, the pressure on a 16.5 cm wrist is about 20 mmHg and the pressure at the wrist for 21.5 cm is about 30 mmHg. The pressure determination usually assumes a circular cross section to assure consistency. However, the cross section at the wrist is not circular, and even less so at the palm.
Although LympheDIVAs publishes a graph showing the pressure vs. circumference (Fitters Aid ©) corresponding to each of our measurement points, other manufacturers are silent on this. What size ranges don’t tell you is when a patient’s specific measurement creates a problem. For example, when the wrist circumference is at the smaller end of the range and the elbow is at the upper end of its range, pressure at the elbow could exceed the pressure on the wrist, potentially creating a tourniquet effect at the elbow. The problem is unlikely to occur if the patient is in the middle of the range in all areas. A custom garment would be indicated for these relatively unusual proportions because the manufacturers can accommodate for that particular problem, however, the specific level of compression for these custom garments is still not provided by the manufacturer.
The therapist is often flying blind with respect to what the pressures are along the sleeve in an off the shelf garment and often resorts to a custom “just to be safe.”
It is strange that custom-made sleeves are classified only by a range of compression, just like ready-made garments. If the manufacturer knows the properties of the textile and knows the circumference of the sleeve and arm, then there should be a number such as 25±2mmHg provided for each measurement point. Unless the therapist or patient has access to equipment to measure the pressures of the sleeve, they are also flying blind when they receive a custom garment.
Ideally, a LympheDIVAs Fitters Aid© type of chart would be useful in selecting a well fitting ready-made sleeve.
A compression garment, no matter how well made and fitted, does not work if it is not worn. More manufacturers are discovering that a sleeve that does not look medical, has a fabric with wicking properties, and is breathable and lightweight is more likely to be worn. The issue of fitting remains, and can be an art form in itself, in order to provide the maximum pressure that can be tolerated. Stories are often repeated that the coarse, hot, and heavy flat knit sleeve is only worn to the therapist’s office.
Custom made sleeves vary in cost from $150 (~R2000) to $700 (~R9000) and often need to be obtained twice a year. The yearly cost of $300 (~R4000) to $1,400 (~R18000) is more often than not, out of pocket. The expense is sufficient to not only keep it off their arms, but also keep them from returning to their doctor or therapist.
Since there is not enough science to say whether a custom or well fitted ready-made sleeve is better for the patient, I would place them as equals on that basis. The lack of precise numbers for either a custom or almost all ready-made arm sleeves does not give either the edge. LympheDIVAs is the exception that puts it ahead of both. Ultimately, cost and compliance are the keys. Once compression levels are determined, patients and therapists should approach their decision by deciding what garment is the least expensive that the patient will actually wear. Compression, Compliance, and Cost should be the main determining factors and not brand or manufacturing type. However, if the first sleeve does not perform clinically, a second choice could involve another type of garment.