12 minute read
The right fit is key Learning from experienced compression garment fitters
Yasmin Ejbeck supported the lymphedema community for more than 33 years with compression garment fitting before recently retiring. She shared her experiences with Anna Kennedy for the benefit of our readers.
How did you assess clients' needs?
I would learn about their experiences so far with lymphedema. Was their diagnosis new or had they been wearing garments for a long time? If they were wearing compression; what was the state of their garments, what did they know about them? I tried to understand their attitude by asking questions; How were they feeling? Were they upset by the lymphedema diagnosis? Had they come to terms with it?
What was a common mistake clients made when choosing a garment?
It is important to feel good in what you’re wearing, and appearance is important, but sometimes clients would be shortchanging themselves by choosing fashion over function. They would want off-the-shelf versus custom, or knee-length stockings, rather than the required full pantyhose. Many people were also not aware of their eligibility through provincial health coverage. I would remind them of the number of garments they were entitled to each year and that their garments should still fit properly and be in good shape. Daily washing is important for hygiene, but also to return the garment back to its original shape for optimum compression.
How do you encourage clients to wear their garment?
If the garment is comfortable, they are more likely to wear it. Although some people will never feel entirely comfortable in a garment, by making it better for them they will see the positive effects, and become more motivated. There are people who just won’t wear compression, even if they really need to and that’s sad. Unfortunately, sometimes it took a bad medical situation for them to finally start realizing that compression is necessary to keep their lymphedema from getting worse.
What suggestions would you give new garment fitters?
For a long time I felt that I should have all the answers but you can’t. Don’t be afraid to tell clients, “I don’t know the answer but I’m going to find out for you.” Especially in custom-wear, there’s always a company representative expert who is eager to help. Attending seminars is also good because you pick up information from sharing experiences among other fitters. Finding a balance between what’s a realistic fitting and “how perfect can it be?” is the hard part. It can’t always be perfect. I would often say to clients, “Custom fit doesn’t mean perfect. It’s going to take a while for us to get to a place where it’s going to be good.” Occasionally that never happened.
Do you have any tips on creative measuring around problem areas?
I remember learning at a seminar how to measure in increments of millimeters; to be so careful and measure right between these exact two lines. But that’s just not realistic, because in minutes, that measurement may be different because it’s hot outside, for example. So you have to learn where to add a little bit or take away after you get to know the person. If I was adjusting a measurement, I preferred to make it consistent all the way up or down the limb, as opposed to just problem areas because you don’t want to cause pockets of compression and create an obstacle for lymphatic flow. Keeping a record of what their actual measurements were along with where and how much you increased it is really important. Custom garments offer many more creative options to make problem areas more comfortable, like soft spots, new weaves at the elbow, knee or ankle area and anatomical feet, etc.
How would you measure someone who is very large or obese?
Wrapping the person’s limb in Saran Wrap is recommended (especially for lower extremity). This firms up the area so you can measure it easier. I would also get a sense of how fleshy the limb was and how firm or soft their tissue was. Picking the right style for someone who is large is extremely important.
What would have been one of your most challenging clients?
One client experienced pain and discomfort, even though she wore a very light compression garment. She needed stronger compression, but couldn’t tolerate that, as she was extremely sensitive to the compression itself. We required many tiny tweaks and changes to make her comfortable. Remake after remake became really frustrating. Luckily, she had a positive outlook, a good sense of humor and was very understanding. However she was also realistic and understood that we couldn’t get it exactly perfect every time.
Are there creative options for people who have trouble donning their garments?
Rubber donning gloves are a must. There’s also a silicone gel that you put on your heel, to make it easier to slip the stocking over your foot. This gel is good for blisters as well. One company has a “slippy aid” for sleeves that includes a loop to hang around a doorknob— making it easy to pull your arm away from it.
Some people have no choice but to wrap (bandage) themselves, as they can't pull any compression garments on. There are good Velcro-type garments for daytime use that people like because they are so easy to put on, without any help. It's so important to be realistic to ensure sustainability for people to wear compression for the rest of their lives. Compression for most people is not just "until I get better." It's a commitment for life.
You recently retired after more than 33 years. What did you love most and least about your job?
Watching somebody transition from, “This is something I don’t want to be dealing with, it’s too hard for me” to seeing them smile and feel better once they put on their new garment. That was probably what I loved the most. As for what I liked least; dealing with the bureaucratic paperwork and government health programs! LP
Yasmin Ejbick, Expert Garment Fitter, Toronto, ON. Retired.
Yasmin Ejbeck was a certified compression garment fitter, who also measured and fit off-the-shelf braces and assisted customers with home healthcare purchases. She lives in Toronto with her husband and is enjoying her new retirement.
Alla Hardoon was introduced to Anna Kennedy as her new garment fitter after Yasmin Ejbeck retired. Alla has kindly provided her expertise in garment fitting, as discussed with Anna.
What are your assessment strategies?
My techniques for garment fitting differ from other fitters due to my medical background. I take into account age-related mobility, social status, and what people do for a living.
For example, if the client is a young woman recovering from breast cancer surgery who has had radiation and/or lymph nodes removed and needs to return to work, I must consider her condition and her daily and social life. This can lead to a difficult conversation about what needs to happen for her arm to improve, stabilize and be appropriately managed long term.
Mobility is a significant factor, along with a client’s lifestyle, mental and physical conditions (including the state of their skin and anatomy). My choice for the appropriate garment is very precise, depending on the situation. They could be in one brand initially to preserve the size of their limb and/or decongest further and then move to a different brand to adapt to their social life, as it’s much more comfortable and flexible. For some people, the shape of their limb (arm or leg) is very unique and requires a specific brand. Others may initially be fibrotic and require more rigidity in the garment to reduce swelling before moving on to more flexible and comfortable options.
The stage of their lymphedema and other underlying issues, such as lipedema or other co-morbidities is also essential to consider. People with lipo-lymphedema can experience pain. Although they may require a heavy and sturdy garment, it is a waste if they cannot tolerate it due to discomfort. We have to be careful to not aggravate any pain for any client.
Encouraging garment wear
Understanding the client’s lifestyle, aches and pains, and underlying conditions allows us to accommodate their needs and make the garment work. I approach it as a medical professional and take extensive notes for the client’s chart. I want the garment to work for them from a humane point of view, but also that of a business owner, in order to get the best outcome for my clients.
We are fortunate that garment brands support us so graciously with warranties that cover refittings. If the order needs to be corrected, they will remake a garment once we send them new measurements.
I ensure that my clients are contacted for followup and asked proper questions. I warn them that if the garment folds in a particular area of their body, it is not fitting correctly due to a decrease in size. While this decrease is a reason to celebrate, the garment will not be comfortable, and we need to know about it.
Addressing problem areas
Knowledge of the body’s anatomy is essential. As fitters, we are taught the standard measuring points. However, a particular measurement point may need to be corrected for some people. For example, the recommended measuring point on the arm is exactly the halfway point between the elbow and the top of the sleeve because that is the anchoring point. But if that happens to be the thinnest point of the client’s arm (with no muscle there), we will only hurt the person and create a tourniquet, resulting in a “muffin top” and the sleeve not staying up. It’s the reason I always feel the entire arm or leg to assess the person’s musculature and determine where the garment needs to sit perfectly.
Lack of information
Misinformation or insufficient information can lead clients to make the wrong decision. My initial appointment with every person takes 45 minutes (20 minutes to measure and 25 for education). I cover why they’re getting what they’re getting, what lymphedema is, where it is, and what the garment will do. I make sure I understand what they want from a garment. Some clients are new to lymphedema, while others have worn a garment for the last ten years but were never in the right one. It can be life changing when we put them in the correct garment.
Challenging fittings
The most challenging fitting is not the garment measurement but considering the client’s specific characteristics and life circumstances that dictate their flexibility for compression choices. A person may psychologically understand and be emotionally willing to wear the best garment, but they are not able to due to limited mobility. Often they don’t have a caregiver who can help them, or they are themselves are a caregiver. My preference for bigger legs that have never been fitted in an elastic garment is to start with Velcro wraps to decongest, before we move them to elastic garments, if it fits their lifestyle.
Donning aids
Donning frames for arms and legs make it much easier to put the stocking on the frame and pull the frame to finish it up. Of course we don’t let anyone walk away without giving them a pair of special rubber gloves because we don’t want garments returned because the client can’t get the garment on, or its been damaged with a nail, for example.
Insurance coverage
Insurance companies have become stricter. Some companies now ask for measuring charts, proof of manufacturing invoices, and an updated doctor’s letter with the lymphedema diagnosis and compression level.
We recently had a client who switched to a new insurance company that asked for a letter explaining why a particular garment was necessary. The therapist wrote a letter explaining why the irreversible lymphedema required a custom garment. I provided them with the measurements and packing slip to validate the expense, and everything turned out fine.
Insurance companies have guidelines with charts and may question why more expensive compression garments are chosen over other options. Naturally, they would prefer to cover the cheapest option. They will also question people who want to purchase additional garments over and above what might be covered by their provincial health plan. I suggest spacing out the purchase of extra garments. This makes it self-explanatory to the insurance company that additional garments are needed in-between because the garments are worn so much.
Collaboration with therapists
Communication is key. The best outcomes result from a collaborative approach between the fitter and the therapist. Constant contact involves sending each other emails and pictures and discussing different options that the patient will wear. We can prescribe the best aid in the world, but it’s a waste if they don’t use it and doesn’t fit their lifestyle. We must be open-minded and recommend what best meets their needs and lifestyle.
Alla Hardoon
Alla Hardoon RN, is the Founder and Medical Director of Care-Med Ltd, a Toronto-based healthcare company specializing in orthopedic products, compression garment fitting, and post-mastectomy care. She recently also became an American Board-Certified Functional Nutritionist.
