A Chorus Line of Compression Products
If today's compression products lined a stage to audition for a Broadway show, the directors would have a tough choice selecting a cast. That's because consumers are demanding versatile products that offer both medically graded compression and stylish good looks. As a result, many products have become stars in their own rights.
To support their weight, bariatric clients typically don't push off on their toes when they walk but rather keep a wider gait to prevent falling. As a result, the calf muscles don't compress as they should and the blood backs up. Those who use wheelchairs, or have reduced mobility, experience similar problems. —Dr. Joseph Caprini |
What's more, these products have universal appeal. A product that traverses a wide gamut of conditions, compression hosiery offers a little something for every client. Those who travel long distances benefit from milder forms of compression, while those with more serious vascular conditions find salvation in higher-grade compression products.
But compression isn't just about high kicks and stardust; these products provide one of the only solutions for those with venous disease. Compression hosiery actually helps the calf muscle function more efficiently.
So, get a leg up on the competition while helping to raise public awareness and your bottom line with compression hosiery and socks.
A Lesson in Circulation
Anyone who's walked the show floor at Medtrade has experienced tired, aching legs — a mild symptom of poor circulation. But for some, the implications of poor circulation are much more severe than passing pain and mild swelling.
Think back to your high school biology class and consider the function of the circulatory system. Blood passes down the leg, delivering much-needed oxygen and nutrients to muscles and nerves via arteries. Next, the deoxygenated blood returns to the heart through veins, carrying with it carbon dioxide and waste products.
ENCORE! Dr. Joseph Caprini, director of Surgical Research, Evanston Northwestern Healthcare, says that one of the main reasons for the lack of public awareness about the benefits of compression products is that "too many people, both lay and physician, think they're hard to get on. … This is a very important thing that is a misconception." In fact, a lot of the perceived difficulty can be overcome with technique and helpful application devices. "I can put the heaviest stocking on over my heel without using my hands," he says. "It's really easy." Assisting devices can make putting on and removing stockings easier for those who have trouble bending, especially clients who are obese, pregnant or elderly. For that reason, HME providers must pay close attention to client needs and offer assisting devices when necessary. "Support stockings are more difficult to apply than 'regular' hosiery, so an individual's ability to apply a particular garment should also be considered prior to prescribing and purchase," says Gary Parsons, Truform division, SAI.
The return veins, equipped with non-return valves, prevent the blood from pooling as it moves back to the heart. In the legs, the calf muscles act as pumps.
"The veins are in the muscles," explains Dr. Joseph Caprini, MD, MS, FACS, RVT, professor of surgery and biomedical engineering at Northwestern University Medical School and The Robert R. McCormick School of Engineering and Applied Science, and director of Surgical Research, Evanston Northwestern Healthcare, Evanston, Ill. So, the muscles contract "and the blood gets pumped out of the legs. Unfortunately, many times there are connections between the deep and the surface venous systems of the legs so that instead of the blood getting pumped out of the leg, it leaks to the surface. And that's the varicose veins situation."
Think of the circulator system in terms of pedaling a bicycle on a hilly course. The arteries deliver blood to the legs like a bike travels downhill. The veins return the blood from the legs to the heart like a bike traveling uphill.
"Since the legs are far from and below the heart, blood flow is traveling uphill, against gravity," says Gary Parsons, product manager, Truform division, SAI, Cincinnati. As the bike navigates the uphill route, the path can become harder to travel because of a variety of complications, such as aging or certain medical conditions. For example, non-return valves can stop functioning efficiently, causing blood flow to back up. In other words, the bike moves very slowly uphill, or in some cases, doesn't move at all.
"Since that blood is sitting at the surface underneath the skin, it can't get pumped because it's outside the pump," says Caprini. "So, it collects there and it creates a stagnation, like a stopped up sink."
ENCORE! "Graduated compression stockings must be fitted properly in order to deliver the specified amount of compression at the ankle. Measurements should be taken with a measuring tape first thing in the morning when the legs are the least swollen," says Jennifer Ortiz, FLA Orthopedics.
When fluid becomes backed up, it leaks into the surrounding tissue and causes swelling, says Caprini. "Then you start to get these skin changes and these discolorations and even open sores on the leg.
"You need to put a stocking on the leg to create enough pressure at the surface that will overcome the tendency of the blood to leak to the surface," he says.
So, compression stockings are like higher gears on the bicycle. These products aid blood flow, thereby reducing swelling and pain, and easing varicose veins.
"For people who have chronic swelling and/or pain and heaviness — patients often describe it as heaviness — in their legs because they have varicose veins or they've had blood clots in the past, the stockings are very effective in controlling the swelling and reducing the pain," says Dr. Lois Killewich, of the University of Texas Medical Branch at Galveston and American Venous Forum member.
Graded compression — which is highest at the ankle and reduces in compression as it moves up the stocking — actually mimics the normal way the muscles in the calves squeeze to keep blood from pooling, says Killewich.
"Remember the definition of the stocking: The stocking improves the calf muscle pump," says Caprini. "Therefore, all we need is calf length stockings most of the time."
A Target Audience
"Only 5 percent of patients who should be wearing stockings actually receive them," says Caprini. "And the reason for that is that there's a lack of public awareness, and also physicians just haven't been taught about these products."
But just who are the people who should be wearing compression stockings and socks?
ENCORE! Caring for compression products requires a delicate touch. Though many styles are machine washable, hand washing can prolong the therapeutic life of support stockings, says Gary Parsons, Truform division, SAI. In addition, rough hands, fingernails and jewelry can run or snag compression stockings, says Jennifer Ortiz, FLA Orthopedics, so care should be taken when applying these products.
Compression stockings are most often worn by the geriatric population, says Greg Biddulph, product manager, Juzo, Cuyahoga Falls, Ohio. "Graduated compression found in the stockings helps improve circulation and control edema in the legs that has been slowed by a weakened venous and/or lymphatic condition," he says.
Stockings with higher compression grades target more serious conditions like lymphedema, venous ulcers and deep vein thrombosis (DVT), a life-threatening condition in which a small blood clot forms.
"Stockings are often used as a post-vein surgery support, and to help heal venous ulcerations," says Parsons. "Anti-embolism stockings have been used for many years in hospitals and nursing homes to help maintain blood velocity and prevent venous stasis, or blood pooling in bed-confined patients. Blood pooling can lead to clot formation in the deep veins (DVT). Upon returning to normal activity, the clot may break free and lead to a pulmonary embolism (PE), which has a higher morbidity rate in the United States than breast cancer and AIDS combined."
Alarmingly, "only 25 percent of people even know what blood clots (DVT) are," says Caprini.
Obesity is a condition that complicates venous activity. "Obesity can put additional stress on the venous and lymphatic systems," explains Biddulph.
To understand how added weight stresses the venous system, Caprini says one must consider the way an obese person walks. To support their weight, bariatric clients typically don't push off on their toes when they walk but rather keep a wider gait to prevent falling. As a result, the calf muscles don't compress as they should and the blood backs up. Those who use wheelchairs, or have reduced mobility, experience similar problems.
In some cases, diabetes can complicate venous functioning, resulting in the need for compression products. In fact, sometimes compression stockings can be used to heal diabetic leg ulcers.
"You have to be careful with stockings and diabetics," says Caprini. "Sometimes with a diabetic ulcer, you will use a compression stocking under certain circumstances to help heal that ulcer because the person doesn't just have diabetes." Some diabetics also have a combination of arterial disease and venous stasis, or chronic venous insufficiency, which prevents the blood from getting out of the legs normally, he says.
Caprini says there are many reasons for venous stasis, which is common in diabetics. It could be caused by obesity, genetically bad valves or prior blood clots.
The Compression Cast
Regardless of the conditions present, "virtually everyone is a candidate for therapeutic, graduated compression stockings, either due to age, occupation/lifestyle, pregnancy, general health (or) genetic propensity for circulatory difficulties in the lower extremity," Parson says.
To target different conditions, support stockings come in a variety of compression grades, measured in millimeters of mercury (mmHg).
ENCORE! Many times travelers on long-haul flights wear compression stockings to decrease the risk of developing deep vein thrombosis (DVT).
Moderate compression choices, rated at 10 and 20 mmHg, are available without a prescription for very mild symptoms. For example, Caprini says a good travel stocking, for long flights or car riding, should be 20 mmHg. Also, surgical hose, used to prevent blood clots for people who are bed bound, come in compression ranges from 8 to 18 mmHg. Caprini warns that when a patient begins moving around, moderate surgical hose is no longer effective in helping improve the calf muscle function. Those patients should switch to higher grades when walking.
Prescription-only stockings, rated at 20-30 or 30-40 mmHg, target more pronounced symptoms and conditions. Caprini says 20-30 mmHg stockings offer basic pressure for people with mild varicose veins, while 30-40 mmHg stockings are for those with more severe problems such as significant medical leg swelling or larger varicose veins.
"Unless you know what the pressure in millimeters is and you know what that means, you don't know if you are getting (a product) that's really good for you," says Caprini. So, offering products that clearly state the compression gradient is vital.
A New Compression Troupe
Variety isn't just in the compression grade for today's products. Manufacturers now offer more choices, targeting everything from body type, to gender, to fashion, to cost containment.
"Consumers want to look and feel their best," says Parsons. "Manufacturers have responded with designer-knit patterned support socks for both men and women; sheer support knee-high and thigh-high stockings, and pantyhose. Many of these styles resemble high-end department store garments."
ENCORE! "If you stand still and you do six toe tips, you'll pump 70 percent of venous blood out of your legs," says Dr. Joseph Caprini, director of Surgical Research, Evanston Northwestern Healthcare.
The move away from medical-style compression has resulted in an explosion of choices in casual dress wear, helping men find an option outside of the panty hose arena, says Jennifer Ortiz, product manager, FLA Orthopedics, Miramar, Fla.
"For men, support socks are available in a variety of knitting styles, fabrics and lengths," says Parsons. "Garments that look exactly like a dress sock are available in over-calf, thigh-high and waist-high lengths. Support socks are also manufactured to look like athletic socks and casual socks, complete with cushioned soles."
But it's not just men who are enjoying new choices in fabrics, styles and lengths. Biddulph says the compression hosiery market goes leg to leg with trends in women's hosiery.
"Today, fewer women wear skirts and dresses and instead opt for dress slacks and pants," says Biddulph. "In the more traditional hosiery market, this has resulted in a dramatic drop off in hosiery sales in the past 10 to 20 years. New innovations in the hosiery industry have led to new products, such as patterned stockings, open-toe and footless designs. These trends are making their way into the medical marketplace as some manufacturers are offering sheer open-toe compression stockings, patterned socks or, in Juzo's case, a new patterned hosiery product offered in diamond and striped patterns."
Parsons attributes these changes to a trend to appeal to younger consumers who want to take care of their leg health in style.
More choices for style also mean more choices for body type — including bariatric clients.
"Individuals with difficult figure types face a unique challenge in obtaining compression stockings that fit properly," says Parsons. "In the past, a made-to-measure stocking was the only option. Today, ready made bariatric sizes are available."
Compression stockings rated below 30-40 mmHg are not reimbursed by the Centers for Medicare & Medicaid Services (CMS). For that reason, keeping prices affordable is important as well, says Parsons — a fact manufacturers also take into consideration.
At the Box Office
"Virtually everyone experiences a decline in leg circulation and can benefit from compression hosiery," says Ortiz. "Therefore, everyone is a potential customer."
In fact, the client base includes both HME consumers and their caregivers, says Parsons. "Hosiery is a cash sale item that wearers will use for life, and typically purchase in multiple pairs per store visit. There is little or no wait for reimbursement."
That trend isn't expected to change anytime soon. "Strong growth is predicted over the next 20 years as the population ages, and as risk factors for venous disorders, such as obesity and heart disease, continue to rise," says Ortiz.
So, how do you tap into the compression marketplace?
According to Ortiz, it's as easy as creatively displaying the products in your store. "HME providers can visually sell graduated compression socks and hosiery by having an attractive display that offers a full range of styles (knee high, thigh high and pantyhose) in various compression levels (9-12 mmHg, 15-20 mmHg, 20-30 mmHg and 30-40 mmHg) and colors," she says.
Parsons agrees that point-of-sale signage and displays are the way to go. In addition, "incorporate a leg health component into other special events/open houses" to drive awareness for consumers and physicians, says Parsons. He suggests giving out support hosiery as door prizes at these events.
Some other suggestions to drive traffic to your store include:
- Sending educational mailers — Ortiz says to send these to both consumers and physicians to educate them about the benefits of compression.
- Leg awareness days — Biddulph says to include vein screenings and specials on stockings and socks.
- Special promotions — Consumers are always looking for a way to save money, says Biddulph. Keep a mailing list of all customers to announce special promotions.
A half-hearted commitment will actually hurt business, warns Biddulph. "Compression stockings and support stockings can boost an HME provider's sales if they make it part of their core business model," he says. "This commitment requires marketing to physicians and consumers regarding the availability and benefits of these products. It also requires having a variety of products to choose from and having them readily available. If consumers have to wait a few days for the arrival of a product, then they might opt to purchase it online instead."
Link UP: Visit the American Venous Forum to view educational videos, featuring Dr. Joseph Caprini, on the rationale and use of compression therapy and proper application techniques. The videos are available in both Hi and Lo bandwidth Quicktime versions and were made possible by an educational grant from Juzo Inc.
www.venous-info.com/education/compthervideos.html
This article originally appeared in the February 2007 issue of HME Business.