by Jonas Thelin

As a certified orthotist and prosthetist, Ray Fikes had been frustrated by compression garments (just like everyone else) during his 33 years of practice, not only because they were extremely difficult to fit but also because of poor patient compliance. He became used to selling the garments as prescribed only see his patients return a few days later wanting their money back, as there was no way that they could don and doff them. With that backdrop, Ray set out with the goal of making an assistive device that would work in all fitting scenarios and with all compression strengths, that could effectively be used by either caregiver or patient a device that could be as effective in doffing as it was donning.

The Concept behind the Doff N’Donner System

The Doff N’Donner system was inspired by the water snake toy that has been around for the last 20 plus years. It is an infinitely shaped water balloon that constantly inverts on itself, exchanging exterior and interior surfaces. In physics, it is referred to as a toroid or torus. The toroid is actually a phenomenon in physics because it is the only instance that we know of where a conveyor belt is not relegated to a frame to do its work.

It was clear that developing a device versatile enough to circumferentially fit any size limb would be a challenge. It would take a material that had at least 800% stretch and a very high tear ratio. The first prototypes were made from silicone because of its ease in gluing the ends of the sleeve together to form a toroid. Silicone worked well in this function and allowed the device to be heated, which was preferable when using the Donner for therapeutic massage. However, the tear ratio of silicone is much less than a thermoplastic elastomer (TPE), and the failure rate was too high. A TPE, on the other hand, had all the qualities that were needed but was extremely hard to glue together since it cannot be heated. Once a company was found that could do this reliably, the Doff N’Donner became a viable product.

Another technical aspect of the development of the Doff N’Donner concept is the length of the device. It was made this specific length in order to permit the garment from being rolled too many times. Every time the garment is rolled by one revolution, it increases the difficulty in deploying the rolled garment. This is a crucial element in the success of the Doff N’Donner. Anyone who has ever tried to simply roll a garment off of their limb can attest to the fact that they could not get it over the heel. This is because the rolled garment is about 15 to 20 plies thick due to the number of revolutions and turns a very delicate material into a substantial rope. To expand on this concept and to accommodate larger garments, two techniques for loading the garment onto the Donner were developed the full roll and half, or partial, roll. The person rolling the garment has absolute control over how many revolutions the garment will encounter during staging (loading) and then application. The partial roll is used when the limb is excessive in circumference, the garment is excessively long, the garment is excessive in compression, and when there is a bulky silicone top band on the garment.

The working concept behind the Doff N’Donner is unique in that the garment is rolled onto and into the Doff N’Donner. As the garment is loaded onto the device, the device takes the shape of the garment. This allows more longevity for the garment because it is not stretched onto a frame or donning device with localized pressure points. Localized pressure is the number one enemy of compression garments, with fingertips following closely behind.

The garment has to be staged, as with any device, but with the Doff N’Donner system, the cone is used to replicate the extremity. Once the garment is staged onto the cone, the Doff N’Donner is introduced and rolled to the bottom of the device where the top of the garment now rests. The garment is then reflected over the Doff N’ Donner, and as the Doff N’Donner rolls, its patented rib design grabs the garment and rolls it up on the outside of the Doff N’Donner.

Recognizing that traveling with the Donner was much easier than with most other devices but that the cone was too large, the arm rolling technique was developed. In most cases, the human arm is much smaller in circumference than the leg that the device is being fitted on. The garment can be pulled onto the arm, and it is used in the same staging technique as with the cone. Once the garment has been successfully rolled onto the Doff N’ Donner, the toe area, whether it be open toe are closed toe, is faced toward the foot with the heel approximating downward. Then the garment and Doff N’Donner combination is rolled onto the limb dispensing the garment by absolute ‘conveyance,’ a term adopted by Doff N’Donner which describes a type of conveyor belt that lays the garment onto the limb and

then pulls it off with no transfer shear on the skin. This means that the garment can be laid on the limb over any combination of bandages or other obstacles and then taken off the same way. It also means that the garment can be donned over a wet limb or one that is freshly lotioned. This is a big deal for caregivers who give sponge baths and previously had to wait until the limb completely dried before they could fit the garment back onto the patient.

Now with the Doff N’Donner engineered for versatility and with multiple rolling techniques, it became clear that application techniques needed to be developed and categorized into patient techniques, which are based mainly on a pulling perspective, and caregiver techniques, which are based on a pushing perspective.

From the patients’ perspective, once the garment is rolled onto the Doff N’ Donner, they have many choices in how the garment can be deployed. They can use a cross-leg-andpull technique, they can use the floor to drive a conveyor action of the Doff N’ Donner, or they can use a surface like the edge of their bed or the front of a couch. Once proficient, these techniques can be used to put the garment on after rolling without touching the garment with their hands. Videos are available on the website for each one of these techniques.

From the caregivers’ perspective, the garment can be rolled onto the limb simply by pushing the exterior of the Donner, which drives the conveyor action and deploys the garment by laying it in place. There can also be a combination where the patient uses the floor technique and the caregiver simply opposes the Doff N’Donner with their hands and the relative movement between their foot and hands drives a conveyor action to deploy the garment. This is called the assisted runway technique. There are videos for each of these caregiver techniques on the Doff N’Donner website as well.

The Components of the Doff N’Donner System

The Doff N’Donner is capable of working for some people all by itself, but because of the different fitting scenarios and preferences in donning and doffing, accessories have been developed to make the Doff N’Donner even more versatile.

The Cone is the most versatile ‘loading’ device for staging a garment in the majority of cases. It allows for a smoother and less wrinkled roll, and the Doff N’Donner is not inhibited by folding onto itself. The Cone is equipped with a silicone suction base that can be adhered to slick surfaces.

The Runway is a strip of material that has been chosen because of its ability to grip two slick services, like wood or linoleum floors, while still being able to grip to fabriccovered surfaces or even carpet. The Runway is used primarily when patients have trouble bending at the waist or cannot cross their legs far enough to use the cross-legand- pull technique.

In institutional usage of the Doff N’ Donner, disinfection or sterilization will be needed. It is also encouraged in domestic usage, but is paramount when a device is going to be used between patients multiple times over. Disinfection bags have been developed for use with the Cone. The bag is simply slipped over the cone, protecting it and the brush fabric from being contaminated, and the garment is rolled on as usual. Once the garment has been deployed on the patient, the Doff N’Donner is reintroduced over the bag and the bag itself is inverted much like the garment would be over the Doff N’ Donner. Once the bag is at a higher level than the Donner itself, isopropyl alcohol or other approved disinfecting agent can be used to disinfect the Doff N’ Donner.

The Doff N’Donner Advantage

It is clear that the Doff N’Donner is superior in most aspects to its predecessors. There is always a matter of preference, but the Doff N’Donner is as much of a science as it is a product. It has been designed from a holistic point of view, with regard to the overall compression industry. Here are some of the advantages of the Doff N’ Donner:

• Ease of use for most patients
• Ease of use for all caregivers
• Can be disinfected
• Cost effective, especially when compared to other systems that require a doffer and a donner, and in many cases, rubber gloves.
• Easy to travel with
• Has therapeutic uses beyond doffing and donning of garments
• Conveys the garment into place by laying it on the limb over any obstacle and removing it the same way
• Can be donned over wet or freshly lotioned limbs
• Easier application of a two-stocking regiment, where one garment is fitted directly over another with no wrinkles, with the ability to doff this combination with no wrinkles and re-don it the same way
• Greatly reduces the number of custom garment scenarios by increasing the ability to fit prefabricated garments that are still within range of the patient size

More Information

For more information on the Doff N’Donner system, please visit www.doffanddonner.com and watch the instructional videos that are available. If there is not a video for a particular scenario that you’re looking for, the Doff N’Donner team would be very interested in hearing about this, and a technique will be developed and a video made if possible. A downloadable curriculum for the Doff N’Donner has been developed (also on the website) and the team is working on getting CE U accreditation.

As for what the future holds, Ray says that he won’t be happy until every donning scenario has been conquered and the donning scenarios that work now are made easier.

Ray says that we’ve come a long way with the Doff N’Donner with regard to applying and removing compression garments, but there are still many inefficiencies and misconceptions about compression garments that need to be conquered. From all our experiences with the Doff N’Donner, we know now that the answer is right in front of us, we just need to keep looking!