Bandaging is an essential element of complex physical decongestion therapy. The therapist usually applies a bandage after manual lymph drainage treatment to enhance and/or preserve its effect.
In lymphedema, manual lymph drainage will result in a volume reduction. The success of therapy is preserved by subsequent compression therapy using bandages and compression stockings. The compression increases tissue pressure and lymphangiomotoricity, and enhances the joint and muscle pump. The efficacy of this treatment is contingent upon the compression pressure applied, the materials used for compression and padding, and the range of mobility afforded while compression is applied.
Lymphological compression dressing:
Lymphological compression dressingThe lymphological compression dressing is an indispensable element of treatment in the temporary initial phase (decongestion phase) of combined physical decongestion therapy, together with manual lymph drainage, systemic skin care, and (decongestive) physiotherapy. It is thus all the more surprising that the lymphological compression dressing is much too rarely included in prescriptions on an outpatient basis. It would be no problem at all to use this treatment option with perfectly good success even in an outpatient setting for non-complicated (primary or secondary) lymphedema of mild to moderate severity, in patients with stage II chronic venous insufficiency, or in the countless patients presenting with postoperative or post-traumatic swelling.
Effects of the lymphological compression dressing:
• The rise in tissue pressure reduces the increased ultrafiltration of the capillaries.
• The edematous fluid previously displaced by manual lymph drainage cannot flow back (success of treatment is preserved and optimised by the lymphological compression dressing).
• The external resistance provided by the bandage greatly enhances the efficiency of the muscle and joint pump, in particular with regard to the elastic insufficiency of the skin commonly associated with lymphedema.
• The re-absorption surface is increased (particularly in postoperative post-traumatic edema).
• By using special foam padding materials, e.g. Rosidal soft®, Komprex®, Komprex II®, which typically have an uneven or wavy surface, proliferated sections of tissue affected by lymphostasis are loosened up.
Specific effects of the lymphological compression dressing on veins:
The circular pressure exerted by the dressing constricts the lumen of the veins, thus preventing venous valve insufficiency.
• The narrowing of the vein results in an increased flow rate (thrombosis prophylaxis).
• The blood volume in the veins of the bandaged limb (»venous pool«) is reduced.
In order to convince the patient of lymphological compression dressing as a temporary aid for edema reduction, it is essential that the physician and physiotherapist “speak the same language”. The patient has to be alerted to the fact that manual lymph drainage without the use of a lymphological compression dressing will only result in a chronification of his/her condition. Furthermore, there is the common misconception that a lymphological compression dressing can be replaced by wearing a medical compression stocking. Within the three-to four week decongestion phase, the lymphological compression dressing is freshly applied at daily intervals, and continually adapted to the decreaed limb circumference.
A (flat-knit, custom-fit) medical compression stocking maintains the volume reduction previously achieved in the lymphostatic limb; it is thus indispensable in the second, preserving phase of a combined physical decongestion therapy. Ultimately the patient has to realise that the prescribing physician and the attending physiotherapist are merely “experts” whose expertise the patient can actively employ to achieve the desired outcome. In any case it is up to the patient to use the self-discipline and persistence required for this purpose. If a patient fails or refuses to cooperate over a prolonged period of time, continued treatment on an outpatient basis is, after all, pointless and uneconomical. This should be clearly pointed out to the patient by the prescribing physician and the attending therapist. This situation is one potential reason for treatment occurring primarily on an inpatient basis.
Application of a lymphological compression dressing in an outpatient setting:
If possible, the patient should supply all the materials required for the lymphological compression dressing before the first manual lymph drainage treatment session in the decongestion phase. The “lymph sets” specifically composed for different kinds of extremity lymphedema and provided by various manufacturers (e.g. Lohmann & Rauscher: arm small/large, or leg small/large, with synthetic padding bandages or foam rubber) have been used with good success.
Lohmann & Rauscher MedicalIn an outpatient setting, it is recommended to apply the first compression dressings with mild pressure. Patients may experience the impressive effects of a lymphological compression dressing and—by providing continual feedback on a daily basis—they are actively involved in adapting the therapy to his/her individual needs. For instance, when initiating treatment in extremity lymphedema, it may be appropriate to use only a mild finger/hand or toe/foot bandaging at first. In patients with chronic venous insufficiency, a lymphological compression dressing makes sense only if it includes the entire lower leg right from the beginning. In this case as well, the therapist can first apply a milder version of the pressure gradient that is typical in all lymphological compression dressings, with a continuous decrease from “high” (distal) to “low” (proximal). Instructions for bandaging in accordance with this report can be found here, or on the “downloads” page.
The foremost principle for applying a lymphological compression dressing is that it must never be painful. In extremity lymphedema, the lymphological compression dressing should be applied up to the root of the extremity or beyond only after the lymphatic drainage pathways at the root of the extremity are largely rid of lymphedema. By choosing the appropriate bandaging materials, the therapist can control the “depth” of effect (epifascial and/or subfascial plane). Short-stretch bandages are typically used for compression of primary and secondary lymphedema, as well as for combination types (phlebo-lymphedema, phlebo-lipo-lymphedema). A short-stretch bandage provides high working pressure and relatively low resting pressure.
As opposed to a rubber-elastic long-stretch bandage, which will cause strangulation and disturb blood supply in the skin due to high resting pressure, a short-stretch bandage is adequate for treatment of lymphedema. In bandaged extremities, protruding bones or tendons often become irritated by the high exposure to pressure. This can be avoided by using appropriate padding around these areas. When the padding is applied directly on these “problem spots“, this will cause a further increase in pressure! The massaging effect that the bandage exerts on the tissues below can be enhanced by inserting high-density rubber foam segments. Thus even the toughest proliferations of connective tissue can be loosened up.
Prof. Dr. Weissleder
Lohmann & Rauscher
An initiative of EWMA (EUROPEAN WOUND MANAGEMENT ASSOCIATION) and Lohmann & Rauscher: In Europe, the knowledge about the etiology and treatment of lymphedema varies widely among experts in the field, notwithstanding the enormous physical and mental strain it puts on patients.