Judith R. Casley-Smith
Compression garments and compression garments, are probably the most difficult problem we have had in the maintenance and control of lymphoedema before, during and after treatment. These are not yet completely solved. However the situation is a great deal better than it was when we started Complex Physical Therapy (C.P.T., Complex Lymphatic or Lymphedema Therapy - C.L.T.) in Australia, in 1987. They are an absolutely essential adjunct to this treatment.
Bandages are essential during C.P.T., since the limb's size changes rapidly and so the size of the compression 'garment' and the amount of compression must also change rapidly. They are necessary partly because of the destruction of the elastic fibres of the skin in lymphoedema, to maintain the reductions gained by massage in the newly lax tissues, and to reshape the limb - using specially shaped padding. They will also cope (via the addition of special padding) with the variation in limb size from one area to another, e.g. a large bulge to a much more constricted area, which a compression garment cannot control.
In palliative care, bandages (and, particularly, garments) are often contra-indicated, unless they provide relief for the patient.
If the patient is able to bandage themselves after treatment, then they may find that bandaging at night, rather than wearing a compression garment is much more comfortable. It is certainly preferable to wearing a compression garment which becomes too tight to permit sleep. The bandaging may need to be redone during the night. (This increase in size and the aching of a limb at night is due to the lack of movement which causes a lessening of the pumping by the tiny initial lymphatics.)
A bandage at night is also more comfortable than an 'elastic' compression garment because of its low resting pressure (see below); garments have to be made more elastic than bandages simply so that it is possible to get them on. However bandaging in place of wearing a compression garment at night is only preferable if the patient has been properly taught the principles of bandaging and is able to bandage the limb without causing damage.
If a garment is worn at night, it may need to be of a lower compression. At night, if necessary, one can use a garment that is starting to wear out. It is important to keep as much compression as can be tolerated (i.e. as close as possible to that used by day).
Bandaging over the compression garment is also recommended during long aircraft flights. The low cabin pressure (as well as the long time sitting motionless), can cause swelling even in spite of a pressure garment which is normally quite adequate. This is especially important immediately after a course of C.P.T., when the limb is very vulnerable!
Bandaging at night and in aircraft is particularly recommended for patients whose lymphoedema has a hyperplastic component, i.e. with mega-lymphatics in the subcutaneous tissue and other areas. (This hyperplasia is often associated with too few deep collecting lymphatics.) Elevation at night is also recommended for these, and for those with lymphoedema whose limbs are still soft and pitting.
Indeed if a patient's limb reduces overnight without a garment or bandages, then it is not necessary for them to wear one at night. If it increases without these aids, then they must wear one at night. They must also of course wear one during the day.
How to Choose and Apply Correct Pressure Bandages
There is a problem about how elastic bandages should be. Some elasticity is essential if they are to permit movement (of both joints and muscles) and if they are to fit closely around the curves.
On the other hand, if the bandages are too elastic they are useless. As a limb is moved, it presses or relaxes against the bandages and the total tissue pressure will vary; this variation is inversely proportional to the elasticity of the bandages. During walking, the greater the variations in total tissue pressure, the greater is the lymph flow (and, incidentally, the less frequently venous ulcers develop and the more rapidly they disappear). Hence the less elastic bandages are, the greater will be the variations in total tissue pressure, with all their benefits for increased movement of fluid in the interstitial tissue, uptake by the initial lymphatics and transport by the collecting lymphatics.
A compromise must be achieved. Limbs which will be subjected to extensive movements should have much more elastic bandages than those that probably will only be moved to a small extent. The more elastic bandaging will facilitate movements. If the movements are extensive, the tissues will be subjected to a range of total tissue pressures similar to those experienced by more rigidly encased ones subjected to lesser motions. The supporting bandages of a sportsman with a mildly torn ligament should be more elastic than those around the lymphoedematous leg. When the sportsman is relaxing, his bandages should also be much less elastic.
Which bandages to use in the clinic situation or after treatment depend on a number of things. They must be able to maintain the required compression. This means that they must be strong and able to be tightly pulled, and durable.
The principles of bandaging for lymphedema should be carefully followed:
A sleeve or stocking of gauze which can be changed and washed daily should first be put on. Do not cut this to the length of the limb; it needs to be almost double this length so that it will be the right length when stretched sideways, and to allow for shrinkage.
Fingers or toes may need to be bandaged separately at this stage.
Suitable padding should be applied, starting at the distal end of the limb (the foot or hand) and working up the limb towards the trunk. This is to prevent indentations forming from the outer bandaging and to equalise the pressure over the entire limb. It will also prevent chafing and protect any tender areas.
As well, foam padding (of various densities, shapes and formations) is applied to shape the limb, fill hollows, even-out pressure of the outer bandage, and break down fibrotic areas.
Finally, the low-elastic (low-stretch) bandage is applied.
Again one starts at the distal end of the limb and works up. The width of the bandage increases, with the smallest width being used adjacent to the fingers or toes, and gradually widening as bandaging progresses.
A very wide one may be used around the abdomen, to the waist if necessary. This can be achieved by joining bandages together, end-to-end (for ease of application) and also side-to-side to make a wide enough bandage. (Use a zig-zag stitch.) An even gradation of pressure is essential. This must be greater at the fingers or toes and gradually decrease towards the trunk.
There are a number of methods of bandaging, all of which work. The use of an extra outer layer of bandaging to provide extra compression allows a patient to remove just the outer layer at night if it is unendurable. The knee joint should be bandaged in an extended position.
If you have trouble keeping the bandage up, 'Handygauze Cohesive' or 'Surgifix' (tubular elastic net) - Beiersdorf - can be used for a few winds under the last part of the bandage. You should also firmly tape the end of each roll to the previous one.
Bicycle pants (Lycra) also help hold the top bandages in place without putting too much pressure on the thighs. A panty-girdle can provide extra abdominal pressure, but must NOT cut in at the waistline.
Orthopaedic, or adjustable, open-toe shoes are good during treatment. These accommodate the extra bulk during treatment and are available from a number of surgical suppliers.
Care of Bandages
Bandages must be washed frequently. This not only keeps them clean, but helps them to regain their shape and elasticity. They should always be rolled, under tension. Do not attempt to apply unrolled bandages. Always apply bandages so that the roll is uppermost, facing you, and rolling away from your fingers - thereby applying the bandage from underneath the roll. Thus correct tensioning is easier.
Note that the available finger and toe bandages are more elastic than those for the limb. For this reason, do not apply them as tightly, or with as many layers. The tips of the fingers or toes should not turn white! These bandages are applied by wrapping one digit first and then passing the bandage completely around the hand or foot, just proximal to the digits, before commencing to bandage the next one. This prevents 'webbing'. If there is a bulge, e.g. at the upper part of the foot which creates an indentation between this and the toes, a small role of foam may be used to fill the gap. The above bandaging will also give some extra pressure at this point if it is required.
N.B. bandaging should never be applied so tightly that is causes severe aching or pain. Analgesics should never be used just to compensate for this. The patient should get up and walk around or do some arm exercises. If this does not relieve the pain, the bandage MUST be removed and re-applied. Patients may have to put up with a certain amount of discomfort, bulkiness and tightness during treatment, but they must be vocal and complain if pain becomes a problem.
Bandages suitable for Lymphedema
The lymphatics only pump when they are compressed (by muscular contraction, massage, or other form of pressure) against something solid and unyielding; too elastic bandages just give way and do not compress the lymphatics, which hence do not pump.
A bandage with low elasticity (low-stretch) causes a high pressure within the limb when a muscle contracts (the working pressure), thus compressing lymphatics. The resting pressure, however, is low - i.e. there is less pressure when the muscles are relaxed than would be the case with a highly elastic bandage (high-stretch); hence the lymphatics can fill more readily. This is why bandages are more comfortable at night than compression garments (which usually have a higher resting pressure because they are more elastic).
Crêpe or elastic bandages (including Ace) are not suitable. They have a high resting pressure and a low working pressure, which is just opposite to what is needed. They will not only be uncomfortable and keep one awake at night, but will not control the lymphoedema.
Low Stretch - see suppliers (outer bandage)
Arm: 6 cms -> 8 cms -> 10 cms
hand ------------> upper arm
Leg: 8 cms -> 10 cms -> 12 cmsfoot --------------->
thigh or 10 cm - 12 cm foot to thigh
Padding - see suppliers.
Padding under short stretch bandages comes in a variety of widths. Use as appropriate - usually 6 cm, 10 cm and 12-15 cms.
Tubular bandage used under the padding. It comes in a large number of sizes. This can and should be changed and washed daily. Measure the circumference of the largest part of your limb and divide this by 2. Give this to the supplier. They should be able to work out the correct size to send. Some are softer than others; some shrink with washing daily.
Finger bandages - see suppliers.
These are elastic bandages so apply with care (not too tight!). With many of these, use a 5 cm one and fold it in half, lengthways. Reroll the folded bandage before applying. Wash folded and reroll.
Crepe bandages may be used. They come in a 15 cm width. Even better are two of the 10 cm Comprilan bandages joined edge to edge length-ways (i.e. not end to end!) with a zigzag stitch to maintain elasticity and to avoid overlapping the bandage and making a ridge. This combined bandage may be joined with another similar one (end to end) to achieve the length needed. A suitable panty-girdle which does not exert extra pressure over the thigh bandages may take the place of this.
Adhesive bandages are suitable for venous disorders with only a mild lymphoedematous adjunct. They are usually taken only to the knee, may be left on for three weeks, but not with significant lymphoedema.
The Order of Bandaging is:
1. Fingers or toes - bandage.
2 .Tubular stocking - over whole of limb.
3. Padding over whole of limb (plus foam padding where necessary).
4. Short stretch- outer bandage - over whole of limb.Use tape (never clips) for joining the end of one bandage to the next.
5. A heavy crepe bandage or joined short stretch bandages, around abdomen - if necessary.
6. Handygauze Cohesive or Surgifix or bicycle pants if you have trouble keeping the bandage up or together at the top.S
uppliers of Bandages are listed elsewhere.S
ome vital points for the maintenance of bandages are listed elsewhere.
This document was last amended on 26 March , 2002.
....................COMPRESSION BANDAGING and GARMENTS
The pressure of fluid (hydrostatic pressure) in venous and lymphatic vessels of limbs is greatest distally, and gradually reduces toward the proximal end of the limb. For a compression to be effective it must also apply graduated compression. Only through graduated compression is the potential for a tourniquet effect reduced. This concept applies regardless of the condition being treated.
How Gradient Compression is Achieved:
Compression bandaging compensates for the diminished skin and tissue pressure associated with lymphedema and helps to prevent the limb from refilling with lymph. Bandaging follows every M.L.D.
to reduce the ultrafiltration rate
to prevent the reaccumulation of evacuated lymph fluid
to help break up deposits of accumulated scar and connective tissue
Low Stretch Bandages (extensible but not elastic)
to raise skin and interstitial pressure of the lymphedematous limbto create a high "working pressure" resistance
to keep "resting pressure" low
to improve the efficiency of the muscle and joint pumps
When the treatment is complete, the compression bandaging is replaced with a custom-fitted compression garment to maintain the lymphedema reduction.
Self-bandaging is recommended at night.
A. 15 minutes - 30 minutes
B. Allow additional time if more than one limb or large difficult limbs.