Compression bandages have been used for many centuries to treat wounds and swollen body parts of all types. Today, they play a critical role in the combined physical decongestive therapy and are used in many different ways to treat a variety of edematous conditions except for uncompensated cardiac edema and occlusive disease. The goal of this section is to give each therapist the ability to discriminate between and to correctly apply the appropriate bandaging method to the various forms of edema.
With the decongestion of
-chronic venous insufficiency (phlebo-lymphedema)
-post-traumatic, post-operative edema
we almost always use textile elastic short- or middle-stretch bandages. In rare cases (for example elephantiasis) the therapist can also use rubber elastic long-stretch bandages in combination with the typical bandages. The three types of bandages according to “Gregory” are
1.the textile elastic short–stretch bandagestretch to a maximal 70%
2.the textile elastic middle–stretch bandagestretch 70% - 140%
3.the rubber elastic long–stretch bandagestretch over 140%
The textile elastic bandages achieve their stretch from the cotton fibers or other similar fibers that are woven into the bandages in an elongated position. Thus, they have a relatively small ability to stretch (short- and middle-stretch bandages).
The rubber elastic bandages include both cotton and cotton-coated rubber fibers and thus allow a “long stretch”. The rubber fibers in these bandages have the unique property of wanting to return to their original pre-stretched position (“memory”) and thus exert a high pressure on the extremity surface.
In this context the following two terms have an important meaning:
1.Resting pressure: Resting pressure can be defined as the pressure exerted by the bandage on the tissue at rest and without movement. That means that the resting pressure for the long-stretch bandage increases as the bandage is stretched and that its resting pressure is always higher (due to the “memory” of the rubber fibers) than the resting pressure of a textile elastic bandage.
2.Working pressure: Working pressure can be defined as the pressure that develops between the bandage and the mobile extremity. For example, as a muscle contracts its circumference increases and presses against the surrounding tissue. Since the textile elastic bandages have a limited stretching ability, they do not conform very much to a contracting muscle and thus they have a higher working pressure. In contrast, the rubber elastic bandages do conform to a contracting muscle and thus have a relative lower working pressure than the short-stretch bandages.
Absolute contraindications are
a) uncompensated cardiac edema and b) occlusive disease.
The long-stretch bandage has a higher resting pressure and a smaller working pressure, whereas the short-stretch bandage has a lower resting pressure and a higher working pressure. This difference is caused by the different stretch ability of the bandages.
Secure the bandages with plaster or tape, look under bandage technique.
Effect of the compression bandages
When short- or middle-stretch bandages are used in a wrap, the patient will experience a higher tissue pressure with movement in all tissue regions epi- and subfascial. These bandages have an effect on Starling’s equilibrium, i.e. the relationship of ultrafiltration and reabsorbtion in the blood capillaries. In this case the ultrafiltration encounters a higher tissue pressure. Thus, less water and dissolved substances will leave the capillary so that the lymphatic load is reduced.
Scintigraphic studies by Mostbeck and Partsch have shown that compression bandages reduce the permeability of the blood capillaries to plasma proteins; thus, the lymphatic protein load is reduced.
The increased tissue pressure also leads to a) reduced size of the venous vessels, b) eventually the insufficient venous values close, c) the blood volume (venous pool) is reduced and d) the fluid velocity increase in the veins (thrombus prophylaxis). As long as no pathological changes are present in the arteries, compression bandages will not cause any obstruction of arterial circulation. Studies of venous foot ulcers by Lofferer have shown that the blood volume in the capillaries after a compression bandage is applied increase to 50% of the original blood volume. After several days of compression therapy, the capillary blood flow is increased to approximately double that of its original value. Haid-Fisher and Partsch have shown using isotope lymphography that the lymph transport (lymph stroke volume) is increased using compression bandages.
Note: A correctly applied compression bandage will result in
a reduced ultrafiltration
an increased resorbtion
a reduced permeability of the blood capillaries to plasma proteins
a smaller blood volume (venous pool) in the venous system in the extremity
an increase fluid velocity in the venous system
a closing of insufficient venous valves
an improvement of lymph transport
an improved muscle and joint pump
an enhanced protection leading to an increased functional activity
The purpose of using padding under the compression bandages is to hinder the bandage edges from cutting into the skin and to minimize the pressure on the exposed bony prominences. Padding is also applied so that pressure is equally distributed over the entire extremity. Laplace described the relationship between the outward pressure exerted by the bandages inwardly (P) and the inner pressure exerted outwardly as follows: P = S/R. Thus the inwardly acting pressure P depends on the circumference of the bandage S and the radius R of the compressed segment. This equation shows the importance of applying padding around any bony prominence. When the entire extremity is padded in an equal and symmetrical manner, the therapist will achieve the most equal distribution of pressure possible.
It is important to distinguish between a continuous padding and a discontinuous padding.
The continuous padding is applied to achieve a distribution of pressure with material like cotton rolls, foam rolls and large foam pads.
The discontinuous padding works through a partial increase in pressure during movement to achieve a massage effect that can loosen areas of connective tissue proliferation (lymphostatic fibrosis). For this purpose one can cut small cubes of foam padding and put them into a small sack made out of stockinet which is than applied to the targeted area underneath the compression bandage.
A cotton stockinet is applied first on the patient’s skin before the padding so to prevent any allergic reactions to the padding.
Note: the goal of the padding is to
hinder the bandage edges from acting as a tourniquet
achieve an equal distribution of pressure from the bandages
protect exposed areas
loosen areas of connective tissue proliferation
Compression and movement
The compression bandages can only achieve their greatest therapeutic effect with movement. If many layers of bandages are used on an extremity, the multi-layer bandage can serve as a buttress against the contracting muscle. The epi- and intra-fascial vessels are then compressed and the free interstitial fluid is shifted into other regions; this occurs according to the principle that fluid will always find the place of least resistance when it is compressed.
The so called “joint pump” is described as the movement of a joint and the surrounding fascia with the corresponding tightening and relaxation of the bandages. During this pumping action the blood and lymph vessels are compressed during the tightening phase and are filled with fluid during the relaxation phase. Thus it is important that the joints should be well wrapped, but not to such an extent that joint movement is severely compromised.
Note: The purpose of movement in the bandage is to
increase the fluid velocity in the veins
accelerate the transport of lymph
compress the free interstitial fluid
loosen up the connective tissue proliferation
It is very important to achieve the most equal amount of pull possible for the bandages. This can be accomplished by holding the bandage head in one hand just over the extremity and exerting a pull while unrolling the bandage. The bandage is then given to the other hand and the same motion is repeated.
One must be sure to avoid the common mistake of releasing the bandage tension during the exchange of hands while one is concentrating on the bandaging pattern.
In order to achieve the ideal bandage pressure on an extremity, the hand that holds the bandage head exerts a pull on the bandage while the other hand simultaneously conforms and smooths the bandage to the extremity. This bandaging pattern gives the therapist the possibility of bandaging anatomically difficult areas in a proper manner like the retromalleolar fossa or foot dorsum.
Ideally, the patient will say that the compression bandage feels like a second skin.
The pattern of bandage application is not so important, so long as the desired pressure is achieved and no pockets of edema or skin cuts develop. Special bandaging instructions can help correct some orthopedic problems and lead to a functional and protective bandage. It is of extreme importance to the removal of edema, that the bandaged patient can move properly.
One must remember when bandaging that the muscle circumference may increase in the muscle belly with movement and not in the muscle origin or insertion.
One must check the distribution of pressure after bandaging in the leg with weight bearing and in the arm with muscle contraction to ensure that the pressure is greatest distally and least proximally.
When the therapist is finished, the bandage should be secured with tape and not the typical clips so to avoid any risk of patient injury. In addition, one can add corrective taping to the bandage to achieve a correct foot position so that the patient can achieve a regular level of activity and/or avoid a damaging compression to the foot.
One should also be aware that when bandaging the lower extremity the patient is supine for foot and calf bandaging and the patient is standing for bandaging of the the knee and thigh. Therapists are constantly surprised that the leg muscles, edema and padding shift down about 5 – 10 cm distally when the patient first stands up.
In order to achieve the best bandage fit, the therapist must pay close attention to the final stages of the wrapping in the groin. For males, it is important the patient moves the genitals to the side so the therapist can properly bandage the groin.
Patients requiring arm bandages should sit if possible with the elbow positioned on a cushion to support the arm, so that the patient doesn’t need to hold up the weight of the edema plus that of the bandages.
Note: Be sure to pay close attention when applying the bandage
that the bandage is held close to the extremity
that the tension of the bandage is maintained while changing hands
that the bandage is properly conformed to the exremity
that the pressure of the bandage is checked with weight bearing and/or muscle contraction
Bandages are introduced in stages with patients who have massive edema. For example, bandages are at first only applied to the distal parts of the extremity, so as to avoid a congestion in the proximal portion of the extremity. It is possible to cause edema of the genitals if too many bandages are applied to the leg too quickly. Bandages that cover “small” surfaces and are applied “lightly” produce a “small” lymphatic load. Bandages that cover “large” surfaces and are applied “tightly” produce a “large” lymphatic load. We apply a larger lymphatic load to the proximal part of the extremity. One needs to determine that the lymph can freely flow at the proximal extremity. As soon as it is seen that no edema is caused centrally, bandaging can then proceed proximally.
The Hans Pritschow Center for Manual Lymph Drainage