Night-time compression: a valuable addition to the lymphoedema management toolkit

Lymphoedema is a chronic and progressive disorder resulting from impaired lymphatic system function, triggering an excessive accumulation of lymph fluid in the superficial tissues, which can lead to chronic swelling, localised pain, atrophic skin changes and secondary infections (Whitaker, 2016; Kayıran et al, 2017). Lymphoedema can be primary or secondary in aetiology: the former is related to developmental abnormalities of the lymphatic system, whereas the latter is attributed to the impairment of lymphatic vessels due to an acquired condition, such as trauma, tumour, surgery or infections (Kayıran et al, 2017). To date, there is no cure for lymphoedema, and the condition is associated with impaired quality of life, both in terms of psychosocial and physiological functioning, with pain, skin tightness, heaviness, numbness and reduced range of movement reported, as well as altered body image, anxiety and depression (Thomas et al, 2020). Indeed, a previous study of the impact of lymphoedema on employment highlighted that 80% of patients were absent from work; 9% changed their employment status; 2% switched jobs; and 8% gave up work entirely (Moffatt et al, 2003). Therefore, it is imperative to collaborate with the affected patient to create and maintain an effective management strategy.

Night-time compression: a growing trend

The recommended treatment of lymphoedema is based on a decongestive lymphoedema therapy (DLT), which is composed of two phases: an intensive phase, combining manual lymphatic drainage, multilayer bandages, skincare and physical exercises to reduce volume; and a maintenance phase, which consists of helping the patient to preserve the reduced volume achieved during the intensive phase for as long as possible (Mestre et al, 2017). This latter phase is accomplished through the use of compression garments, such as bandages, stockings and wrap systems. The wearing of these garments in the daytime is a well-established practice in lymphoedema management; however, night-time compression is gaining momentum in the literature. It has been shown that up to 89% of individuals with chronic swelling observed an increase in volume overnight if no compression was used (Whitaker, 2016). This is contrary to the suggestion that limb swelling will reduce or stay the same overnight due to elevation (Chohan et al, 2022)—in fact, 66% of patients (62/94) have reported that night-time oedema was the same or greater than that experienced in the daytime (Whitaker, 2016)—or that night-time compression will exacerbate swelling.

On the contrary, research is increasingly demonstrating that night-time compression can be extremely beneficial in both primary and secondary lymphoedema. A study collecting quantitative and qualitative data from 94 participants across five countries demonstrated that 45% of patients reported a reduction in oedema from using night-time compression, and all patients could spontaneously name two or three associated benefits, namely: better management of their oedema; reduction in pain; and a sense of relief that continued into the daytime (Whitaker, 2016). Half of all night-time compression users in the same study felt a 24-hour benefit; 60% said they noticed a negative difference for all or most of the day when they did not wear night-time compression; and 65% felt that using night-time compression helped them to better manage their oedema (Whitaker, 2016). Additionally, when collecting limb circumference data, Whitaker (2016) found that, in 86% of measurements of the thigh and 87% of the ankle, oedema was reduced or maintained at the same level; similar results were achieved at the upper arm (83% oedema reduction or maintenance) and wrist (86%). An observational study involving 91 patients wearing night-time compression over a 21-day period revealed that the entire sample wore the night-time compression garment for means of 6.5 days per week and 7.9 hours per night, which represented a marked improvement over compression bandages (50% of patients wore these at least 3 times per week), the predominant means of compression prior to the study (Bertsch, 2018). Only 7% of the sample occasionally removed the garment due to heat or perspiration, and 94.5% rated the night-time compression garment as ‘good’ or ‘very good’, with high rates of satisfaction reported in areas such as ease of use and comfort, tolerability and quality of sleep attained (Bertsch, 2018). Similarly, McNeely et al's (2022) parallel 3-arm, multicentre, randomised trial among 118 Canadian women with breast cancer-related lymphoedema demonstrated a percentage excess lymphoedema reduction of 1.5% ± 18%, 12.1% ± 16%, and 15.9% ± 22% in the standard care (daytime use of compression sleeve alone), compression bandaging and night-time compression system garment groups, respectively. By centre, significant differences were found in favour of night-time compression system garments over standard care in both Edmonton (P=.043) and Vancouver (P=.013), and a significant benefit of night-time compression system garments over compression bandaging was found in Vancouver (P=.027) (McNeely et al, 2022).

Adverse events related to the wearing of night-time compression garments in McNeely et al's study (2022) were minor and included elbow bursitis (n=1) and discomfort (n=1), and feedback prioritising issues of comfort was given in Whitaker's (2016) study, with 26 participants (28%) asking for a change of material and a further 18 (19%) directly identifying required improvements in comfort. The ideal night-time compression garment would be less tight, would not cut into the skin and would be free of any slippage. Those using a product specifically for night-time wear in Whitaker's (2016) observational study were more concordant with the therapy: 53% used a specific night-time product every night vs 31% who used the same product that they had worn during the day at night. Therefore, it seems important to make specific night-time compression garments available to patients when emphasising the importance of night-time compression, rather than allowing them to use their daytime compression products, to improve concordance and the quality of care provision.

Conclusions

Patient engagement in self-care and self-management is imperative for the effective treatment of lymphoedema, and any methods which reduce the physical manifestations of the condition while improving the affected person's quality of life seem worthwhile to explore. As discussed, night-time compression appears to be a viable and effective addition to a patient's lymphoedema management toolkit; however, to improve concordance, it is imperative that the garments chosen are not overly restrictive, encourage airflow while maintaining compression, and are easy to don and doff. There are many available options, summarised in Table 1. Whichever method is chosen, the emphasis must be on empowering the patient while successfully controlling their oedema, enabling them to take back control.