The following has been excerpted from "Exploring The Use Of CircAid Legging In The Management Of Lymphoedema" by Eilish Lund, published in 2000 in the International Journal Of Palliative Nursing, Volume 6, No. 8, pages 383-391.

Case studies:
In the following case studies, use of a CircAid legging during the maintenance phase maintained and improved on the reduction achieved by DLT, thereby saving the patients from further DLT. The three patients described in the case studies below were selected from the author's caseload because the distal segments of their affected legs were very large. The case studies are not part of a controlled trial of the product, but report the results of treatment using a novel product.

Case 1 | Case 2 | Case 3 | Conclusion

Case 1: 30 year old male
Brian presented with lymphoedema praecox, affecting the distal segment of both legs. Clinical examination showed a deep skin fold on the inner aspect of his right leg above the ankle; fibrosis; positive Stemmer's sign (a failure by the assessor to pick up or pinch a fold of skin at the base of the second toe (Mortimer, 1995)); and squared toes (a common presentation in advanced lymphoedema of the feet). Brian did not complain of any pain.

Brian's main concerns were:

• His difficulty with footwear due to the swelling of his feet
• Having to wear special trousers. He had to purchase two pairs so that the legs of one pair could be used to make the other pair large enough to fit his swollen legs
• Recurrent episodes of cellulitis, which had started at the age of 14.

Brian had received DLT 8 years previously, that had been followed by a gradual deterioration (over the course of 1 year) to his pre-treatment state.

Brian presented to clinic wearing made-to-measure hosiery (pantyhose-type garment) because the shape of both his legs was abnormal and could not be contained within commercially available garments.

Treatment
Brian received nine sessions of DLT over a 2-week period. His work commitments prevented him receiving further sessions of treatment.

Prior to treatment, Brian's right distal segment volume was 7316 ml. Following the DLT, this was reduced to 4935 ml. The deep skin fold was gradually reduced over the 2 weeks. The left distal segment was reduced from 6061 ml to 4431 ml.

A made-to-measure pantyhose-type garment was ordered, as Brian was not keen to wear the available hosiery. On the final day of treatment, Brian was fitted with a class 3 below-knee stocking on his left leg and a CircAid legging on the right, both worn over his -- now too large -- pretreatment hosiery (only one CircAid was available in stock at that time).

Seven days later, both distal segments had increased in volume: the right to 5654ml and the left to 5153ml. Brian remarked that the legging seemed to feel looser after some time, but that it eventually fitted snugly again as the day progressed. He agreed to tighten the bands as he felt the pressure lessening.

Eight days later the right leg had lost 350ml from the distal segment whereas the left had gained another 30ml.

One month after completion of DLT, the left distal segment had regained all the volume that had been lost during the DLT. The right distal segment had lost 2360 ml. A CircAid legging was then fitted to the left leg, and 24 days later the left distal segment showed a volume reduction of 1600ml.

Twelve months after the second CircAid was fitted, the right leg volume was 3500mi less and the left 2600ml less than prior to treatment (970ml and 1119ml respectively less than at the end of DLT). The skin fold had almost disappeared and both feet were the same size as immediately after DLT.

The greatest circumference measurement on the calf of the right leg prior to DLT was 53.4cm. Following 10 days' treatment, this was reduced to 43.2 cm. Considering that the elastic fibres of the connective tissue had been seriously damaged from the long standing lymphoedema, it is not surprising that in the absence of firm support the tissues would refill. Although the right leg was fitted with CircAid immediately following DLT, the reduction in volume was not maintained. Brian did not adjust the Velcro straps initially, and slept in the garment for the first few nights. Once he got used to the device and correctly tightened the straps as the day advanced, the volume of the leg was progressively reduced.

The left leg regained most of its volume in the month following DLT, but responded rapidly to the application of a CircAid legging. A 1600mI reduction in volume was achieved in 3 weeks. Brian can now wear ordinary jeans and trousers and has no further episodes of cellulitis.

Case 2: 69 year old male
Reg presented to clinic with lymphoedema tarda of the entire right leg. No truncal oedema was detected. The lymphoedema had developed suddenly 25 years previously, at which time the possibility of DVT was investigated and discounted. Reg's lymphoedema had deteriorated steadily since its onset. Reg's right-leg volume was 98% greater than that of his left leg: the distal segment was 153% greater, and the proximal 58% (in leg volume comparisons, the total leg volume percentage difference is not an average of distal and proximal percentage differences).

Clinical examination showed skin folds, fibrosed tissues, positive Stemmer's sign and squared toes, but Reg did not report any pain. In 25 years, Reg had not received any treatment for his condition.

Reg's main concerns about the lymphoedema were his inability to wear off-the-peg trousers and his need to buy larger shoes for his right foot. His right calf measurements were 20 cm larger then his left, and his mid-thigh measurements 10 cm greater.

Reg was given 14 sessions of DLT over a 3-week period. This achieved a volume reduction of 2500ml in the right leg. The total difference was reduced to 57% (102% for the distal segment and 30% for the proximal segment).

On the final day of DLT, Reg was fitted with a fully-knitted stocking with waist attachment, which he was advised to wear day and night. A maintenance programme was also devised.

Two weeks later, the volume difference had increased to 71%. Reg's trunk and leg were then treated with MLD twice weekly for 2 weeks followed by 3 days' DLT. This reduced the volume difference to 64%. A CircAid legging was fitted to the lower right leg with a foot wrap. Reg was encouraged to comply with the maintenance programme of skin care, SLD and pumping exercises while wearing the legging.

Reg stopped wearing the foot wrap within a week because he found that it did not fit comfortably in his shoes. He then wore the legging daily with class 3 hosiery for 15 months. His right-leg measurements decreased slowly to being 57% greater in volume than his non-affected leg.

The limb volume charts for the distal and proximal segments show how the fluid in Reg's leg shifted initially to the proximal segment and eventually drained away with SLD and exercise.

Fifteen months after fitting with a CircAid legging, Reg resisted a suggestion by the therapist that he should try hosiery alone. He stated that the firm support of the legging was very comfortable and he would be prepared to purchase the garment privately if it was not supplied by the clinic.

Case 3: 78 year old female
Iris presented in 1997 with lymphoedema tarda of the whole of the left leg, but with no truncal or foot involvement. The condition had developed suddenly at age 60 following an accidental kick. DVT had been ruled out and a lymphangiogram several years after onset confirmed the diagnosis of lymphoedema. Previous treatment had consisted of a thigh-length class 3 compression stocking supplied by the surgical appliance officer of her local hospital.

Clinical examination of Iris's leg showed skin changes, fibrosed tissues, skin folds, and a large limb-volume difference (91% in total: 150% in the distal section, and 57% in the proximal section). The distal segment was distorted, and the weight of the leg had caused postural changes and back pain. Iris described her leg as 'feeling full' but it was not painful.

Iris's main concerns regarding her condition were:

• Body Image
• Obtaining Comfortable Hosiery
• Back And Joint Pain

Iris was given 14 treatments of DLT over a 3-week period. A volume reduction from 150% to 45% was achieved after 3 weeks' treatment. She was then fitted with class 3 hosiery, a thigh-length stocking with a waist attachment, and taught self-care. She was monitored every 3 months. Over the following 9 months the volume difference increased again to 76%. A second course of DLT over 2weeks reduced the limb to 54% difference. The distal segment was 76% greater and the proximal segment 40%, greater than the unaffected right leg. At the end of this course of treatment. Iris was fitted with a CircAid legging to be worn over her thigh-length stocking.

Over a 6-month period, the limb gradually' refilled again, the distal segment volume increasing from 76% to 140% greater than the right side. The proximal segment changed very little. A third session of DLT was undertaken, which reduced the affected limb volume to 55% greater than the unaffected limb. Iris's limb volume remained static for 10 months with a combination of class 3 hosiery plus a CircAid legging.

At the end of this 10-month period, and with Iris's consent, the CircAid legging was removed for 1 week to monitor volume changes. The distal segment increased from 61% to 74%. Iris missed the support of the rigid structure of the legging and was pleased to have it reapplied.

Iris's affected leg has lost 2000 ml in volume -- approximately 2 kg in weight -- since initial assessment by the author. As a result, Iris has improved mobility and has experienced relief from her back and joint pain.

It is not clear why Iris needed another course of DLT following use of the CircAid legging. She had a serious pneumonia during the time and was not wearing her hosiery continuously. It may be that compliance was not as good as with the other patients, and that having to have another course of DLT strengthened her resolve to take the time to apply the garment daily.

Iris now wears ordinary tights and a skirt over her CircAid legging. She finds the legging easy to put on; however, the Velcro damages both her tights and the compression garment worn underneath the legging.

Conclusion
One of the indications for use of the CircAid legging is severe swelling of the distal segment of the leg. The rigid construction of the garment enhances the effect of the muscle pump. Adjustment of the Velcro straps during the day, as the leg volume decreases with exercise, helps maintain and gradually reduce the volume. The legging currently costs £95 plus tax in the UK. At the author's clinic, it was found that the legging needs to be replaced approximately every 9 months. This will of course be a consideration for large clinics with high hosiery costs.

However, in the three case histories presented here, the legging has improved quality of life, the limbs have improved steadily and the patients are very pleased with the results. Repeated sessions of DLT were not needed except in the case of Iris. A full treatment of DLT takes 90 minutes per leg, amounting to 22 hours for a 3-week course of treatment. Avoiding this treatment can save valuable time in clinics.

Contraindications for use of the CircAid are no different than those for compression hosiery:

• Infection and acute inflammatory episode
• Arterial insufficiency
• DVT
• Severe cardiac failure

Patient compliance appears to be good because of the ease of application and the support achieved. The fact that the results are good also encourages compliance. The limitations are that it does not address whole leg swelling and that the foot wrap is not easy to wear with shoes.

In the our clinic, we have begun to use the legging with less severe swellings of the lower leg in patients with lymphoedema secondary to cancer treatments --with good results. 

Reference cited in text: Mortimer PS (1995) Managing Lymphoedema. Clin Exp Dermatol 20:98-106.