9 minute read
The "science" of custom fitting
The “science” of custom fitting
By Jessica Diamond, Megan Diamond, Claire Ann Deighton, Kim Radford, Dayna Ricard and Jenny Whitlaw
Measuring and fitting compression garments, whether custom-made or ready-to-wear, can be challenging. Learning often comes from experiencing garments that don’t fit and need to be revised.
Throughoutthis article, we will discuss measuring techniques that we use, and we will share specific case studies highlighting what we have learned.
We have a group of six garment fitters in our retail store, which allows us to collaborate and provide continuity of care. We record measuring techniques, past issues and garment modifications on all customer files, allowing the customer to be served seamlessly if their particular fitter is away.
Different fabrics, styles and measuring techniques are used depending on the client’s circumstances. We have over 65 years of experience between us to draw on and use standard protocols for assessing a new or returning client to ensure quality of fitting
Assessment
To begin, we determine the appropriate time for the client to be measured for a compression garment. If the patient first needs their limb volume to be reduced, we discuss Manual Lymph Drainage (MLD) and compression bandaging. We provide a letter for clients to share with their physician explaining MLD and short-stretch bandaging and why we suggest this treatment. Other options for reduction are alternative compression systems, kinesio taping and compression pumps.
There are two challenges that we often face when measuring after the client has completed compression bandaging.
A) Creases in the leg – Our solution: take measurements above or below the crease.
Example of compression bandaging incorrectly applied (too tight & not high enough).
B) Bulging – Our solutions include pulling tight at our last measurement below the knee, or occasionally we reduce by a few cm depending on the severity. We also may add an inside silicone band to help hold the garment in place if the leg has a cone shape.
Example of bulging from compression bandaging that has slipped down.
If the client requires any lymphedema treatment, we try to communicate with their lymphedema therapist regularly. This communication can help us understand the client’s needs and when they are ready to be measured.
Measuring & choosing garments
After the limb has been appropriately reduced in volume, we are ready to measure, taking into consideration compression level, material type and style.
Material type
Flat-knit versus circular-knit (ready-to-wear) options are based on patient history, fluctuation of swelling, and shape of the limb. In some cases, a flat-knit garment is not required and we may choose ready-made garments if the customer is new to compression, has arterial vascular disease, has potential donning issues, financial constraints or is in stage 1 lymphedema, and they fit well into a ready-made product. Below is an example of an individual in a custom circular-knit versus a custom flat-knit garment. It is evident that this customer requires flat-knit compression since the circular-knit is causing a tourniquet effect and binding at the ankles.
Same patient: custom circular-knit (left) versus custom flat-knit (right).
Choosing the manufacturer
If the individual is in the acute reduction phase and continuing with treatment while waiting for their garments, we may choose a company with a quicker turnaround time. Some suppliers produce garments within a week, while others take several weeks. We also may choose manufacturers based on their specific options, materials and warranties.
To begin, we determine the appropriate time for the client to be measured for a compression garment. If the patient first needs their limb volume to be reduced, we discuss Manual Lymph Drainage (MLD) and compression bandaging.
Style of garment
The style of a garment will vary for each individual, but we use certain options on most garments. These include; slant foot, steep oblique/scoop for knee-high, t-heel/yknitting when there is a cuff at the ankle, and double silicone on thigh-high stockings: a 3 cm inside band and a 5 cm top band.
CASE STUDY 1
Age: 54 year-old female.
Medical history: Diagnosed in 1997 with melanoma and had surgery to remove the lesion. Left leg groin dissection in 2001. In 2013-2014 began presenting with lymphedema. 2015 had surgery and radiation for metastatic lesions. Currently has tumours in right and left groin. Lymphedema is managed and stable.
Above: Fibrotic surgery site.
Left: Flat-knit 1 1/2 leg garment.
Garment: First garments were thigh-high ready-to-wear and chap-style ready-to-wear. These garments began to cause fibrosis at the surgery site and led to fluid build-up in the abdomen. Moved to flat-knit 1½ leg panty, Class 1 on the unaffected leg and on the panty portion, and Class 2 on the affected leg. Subsequently, we increased compression to Class 2 in the unaffected leg and panty portion and Class 3 on the affected leg. The customer also uses Velcro wraps and a night garment.
CASE STUDY 2
Age: 78-year-old female.
Medical history: Breast cancer. Right upper limb lymphedema has been stable for ten years.
Custom seamed arm sleeve and glove (old-style burn garment).
Ready-to-wear circular-knit arm sleeve.
Garment: Has been wearing custom seamed arm sleeve and glove since 2009. She did not want to try flat-knit due to the thickness of the material. In 2023 was struggling to don the custom seamed (old style burn garment) arm sleeve. Tried a ready-to-wear circular-knit arm sleeve. This new garment she could don more easily and still manage her lymphedema. Next, we will order a custom circular-knit to improve the overall fit (length in particular).
CASE STUDY 3
Age: 47-year-old male.
Medical history: Injured his back in 2008, which limited his mobility significantly.
Obesity became a big factor. In 2016 he noticed swelling starting in his feet. The swelling progressively worsened, involving his legs and abdomen. In 2018 he had his first cellulitis bout. Currently, his lymphedema is not controlled. He struggles donning garments and has limited access to treatment.
Garment:
First garments were a thigh to ankle garment with separate knee-high stockings and toecaps. The second garments were biker shorts with knee-highs and toecaps. However bike shorts flared out and did not contain the lobule above the knee. To address this issue, we made a male-style capri. Due to the size of the leg, one manufacturer could not make the flat-knit garment, and all vendors could not accommodate the size for Velcro wraps. Current issues with the garment include donning and heat rash. Due to fluid fluctuation, the panty portion doesn’t stay in place. We are still working with the client to figure out how we can improve his garments.
Capri garment.
CASE STUDY 4
Age: 62-year-old male.
Medical history: Workplace injury leading to amputation of left foot. Lymphedema resulted.
Above: Initial garment. Left: Current garment.
Garment: Initial garment was a specialized flat-knit foot cap and knee-high stocking. Over time he was able to transition to a flat-knit closed-toe knee-high for patient comfort.
Continuous reassessment
Lymphedema is becoming more known in the healthcare community, leading to earlier diagnosis. Treatment and therapies are becoming more readily available to patients. As fitters, we recognize the importance of reassessing garment styles, compression levels and materials each
time we replace the garment. Individual lifestyles and needs change over time, so we may need to adjust their garments. We encourage our customers to continue with their Complex Decongestive Therapy (skin care, exercise, compression, manual lymphatic drainage) and see a certified lymphedema therapist regularly.
Their therapists can detect changes in the tissue much sooner than we can visually.
We are continually revising our measuring techniques, and garment choices. What works for one customer may not work for the next. “Custom fitting” is definitely not an exact science. LP
Circular-knit vs Flat-knit Garments – What is the difference?
Circular-knit
• Made from a single tube on a circular knit machine and are seamless
• Different circumferences from the ankle to the thigh are produced with the same number of stitches
• The anatomical shape is created by changing the stitch size and yarn tension which is limited
• The material is usually less stiff and appears smoother
• The material is more prone to cut or settle into skin folds, eventually causing skin lesions
• Available for compression classes 15-20mmHg, 2030mmHg, 30-40mmHg
• Available for both custom-made and ready-to- wear garments.
• Best used for vascular issues or in milder cases of primary or secondary lymphedema
• The sizing is applicable for patients with average and proportionate sized limbs
• All ready-to-wear garments are circular-knit
Schematic representation of a circular knitted fabric. Changes in shape due to different mesh heights and thread tension.
Flat-knit
• Made from an open piece of fabric on flat-knit machines and then seamed
• The machine can be programmed to vary the number of needles; therefore, varying the number of stitches, guaranteeing an individual fit and optimal compression
• The fabric is knitted flat, no fabric tension, no tendency to curl or cut in when fitting irregular shaped limbs
• The material offers more containment
• Made for individual shapes and sizes
• Less likely to dig into your skin, depending on the softness of the material
• Available in different compression classes
• Custom-measure only.
Schematic representation of flat knited fabric. Changes in shape by increasing or decreasing stitches.
Red: Elastic inlay yarn
Blue: Knitting yarn
