Lymphedema Short Stretch Bandages

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Short Stretch Bandages are for Lymphedema

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Short Stretch Bandages

The short stretch bandage is a wrap used in the treatment of lymphedema. It is called "short strech" because of it rating on elasticity. These bandages are rated at 30% to 90%, which means they can stretch up to 90% beyond their actual non extended length. Because of this, they are able to provide continual compression on the lymphedema limb. They work inconjunction with your muscles to help not only prevent additional swelling, but to help lymph flow.

Short strech bandages are used extensively during the treatment phase of lymphedema.

Why Not Use Ace Wraps?

One should not use ace wraps as an alternative for several reasons. Ace wraps are very elastic, able to stretch to several times their original length. As a result, they are not able to provide the needed compression rating on the limb.

Another problem associated with ace wraps is that they can cause irregularities in the shape of the affected limb. Due to the elasticity, it is almost impossible to have an equal and consistent pressure grade on the limb. This "bunching" or irregularity further hinders lymph flow.

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Short Stretch Compression Bandages

Minimally elastic. They compensate for the diminished skin pressure associated with lymphedema, and prevent the reaccumulation of evacuated, stagnating lymph fluid. The more inelastic the bandage is, the greater the potential working pressure (pressure produced when the muscle pump works against the resistance of the bandage, as when exercising). Inelastic and short stretch bandages have advantages over elastic garments because they force a higher working pressure and greater muscle pump efficiency. Conversely, because of the low resting pressure (pressure exerted when the muscle is inactive and relaxed), compression bandages may be worn day and night with good patient compliance.

Compression bandaging is applied in layers. The digits (fingers and toes) are individually wrapped with gauze bandages. A tubular bandage, made of primarily cotton, is worn underneath the compression padding and bandages to protect the skin and absorb excess perspiration. Padding bandages are applied just prior to the actual compression bandages to cushion the limb (especially over skin creases or bony prominences) and to prevent sharp indentations and irritations to the skin. In addition, they serve to distribute the pressure evenly over the limb. The last stage is the actual short stretch compression bandages used to apply the final compression. They are wrapped with mild to moderate tension in an overlapping pattern in a distal to proximal direction.

http://www.knueppels.com/LMT.asp

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Compression Bandages
in the treatment of Lymphoedema

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 lymphoedema
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 Lymphoedema

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 cms

foot ---------------> 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.

Abdominal bandaging

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

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.

Suppliers of Bandages are listed elsewhere.

Some vital points for the maintenance of bandages are listed elsewhere.

This document was last amended on 26 March , 2002.

The Lymphoedema Association of Australia

http://www.lymphoedema.org.au/index.htm

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Examples of short-stretch bandages

Examples of short-stretch bandages are Unna's paste bandage and Comprilan® (Beiersdorf Medical, Charlotte, NC). Ace® bandages are inappropriate as a treatment of venous ulceration. Prescription compression stockings can be used in the maintenance phase of treatment. Prescription compression stockings can be used in the maintenance phase of treatment. Generally calf length stockings are used with 30-40 mmHg or 40-50 mmHg. It is easier for some patients to apply a zippered stocking over a cotton liner (Jobst Ulcercare®; Jobst-A Beiersdorf Company, Charlotte, NC) or to superimpose two 20-30 mmHg stockings (yielding 40 mmHg). Consider intermittent pneumatic compression in patients who don't respond to standard compression measures and in patients who are not ambulatory.

Compression leads to increased venous flow, decreased pathological reflux while walking, and increased ejection volume with activation of the calf pump. Tissue pressure is increased which favors resorption of edema fluid. In order to achieve maximum benefit from compression the patient needs to ambulate.

http://www.phlebology.org/syllabus11a.htm

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A prospective randomised trial of four-layer versus short stretch compression bandages for the treatment of venous leg ulcers.

Scriven JM, Taylor LE, Wood AJ, Bell PR, Naylor AR, London NJ.

Department of Surgery, University of Leicester.

This trial was undertaken to examine the safety and efficacy of four-layer compared with short stretch compression bandages for the treatment of venous leg ulcers within the confines of a prospective, randomised, ethically approved trial. Fifty-three patients were recruited from a dedicated venous ulcer assessment clinic and their individual ulcerated limbs were randomised to receive either a four-layer bandage (FLB)(n = 32) or a short stretch bandage (SSB)(n = 32). The endpoint was a completely healed ulcer. However, if after 12 weeks of compression therapy no healing had been achieved, that limb was withdrawn from the study and deemed to have failed to heal with the prescribed bandage. Leg volume was measured using the multiple disc model at the first bandaging visit, 4 weeks later, and on ulcer healing. Complications arising during the study were recorded. Data from all limbs were analysed on an intention to treat basis; thus the three limbs not completing the protocol were included in the analysis. Of the 53 patients, 50 completed the protocol. At 1 year the healing rate was FLB 55% and SSB 57% (chi 2 = 0.0, df = 1, P = 1.0). Limbs in the FLB arm of the study sustained one minor complication, whereas SSB limbs sustained four significant complications. Leg volumes reduced significantly after 4 weeks of compression, but subsequent volume changes were insignificant. Ulcer healing rates were not influenced by the presence of deep venous reflux, post-thrombotic deep vein changes nor by ulcer duration. Although larger ulcers took longer to heal, the overall healing rates for large (> 10 cm2) and small (10 cm2 or less) ulcers were comparable. Four-layer and short stretch bandages were equally efficacious in healing venous ulcers independent of pattern of venous reflux, ulcer area or duration. FLB limbs sustained fewer complications than SSB.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9682649&dopt=Abstract

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Physical properties of short-stretch compression bandages used to treat lymphedema.

King TI, Droessler JL.

Occupational Therapy Department, University of Wisconsin-Milwaukee, PO Box 413, Milwaukee, Wisconsin 53201, USA.

This study examined the physical properties of six common brands of short-stretch compression bandages used to treat lymphedema. The physical properties examined were (a) maintenance of pressure over a 12-hr period, (b) variability of pressure across the width of the bandages, and (c) variability of pressure when the bandages were wrapped with a 50% overlap. The results of the study indicate that all six brands of bandages tested maintain pressure well over a 12-hr period. Each has a variance of pressure between the middle and edge of the bandage, with the edges measuring (in mmHg) between 6% and 28% lower than the middle. When the bandages were wrapped with an 50% overlap, all six brands measured fairly consistently in pressure readings (in mmHg) across the width. These results indicate that the six brands of short-stretch compression bandages tested have similar physical characteristics.

PMID: 14601819 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14601819&dopt=Abstract

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A comparison of multilayer bandage systems during rest, exercise, and over 2 days of wear time.

Hafner J, Botonakis I, Burg G.

Department of Dermatology, University Hospital of Zurich, Gloriastrasse 31, CH8091 Zurich, Switzerland. jhafner@derm.unizh.ch

OBJECTIVE: To study the interface pressure between the leg and 8 different multilayer bandage systems during postural changes, exercise (walking), and over 2 days of wear time. DESIGN: Comparison of 8 different compression bandages under standardized conditions. SETTING: Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland. PARTICIPANTS: A series of 10 healthy volunteers, 5 females and 5 males, aged 26 to 65 years. INTERVENTION: An electropneumatic device was used to measure interface pressure at 12 points of the leg. MAIN OUTCOME MEASURES: (1) Pressure changes from the standing to the sitting and supine position at rest, (2) pressure amplitude during exercise (200-m treadmill walk at 3.2 m/s, 0 degrees incline), and (3) pressure decrease over 2 days of wear time. RESULTS: Results are given as median with the 10% to 90% confidence intervals. Multilayer bandages of short and medium stretch showed a larger pressure decrease when the patient was supine (eg, 3 short stretch bandages: 18.0 mm Hg [reference range, 15.5-19.5 mm Hg]) than systems of medium and long stretch bandages (eg, 4-layer bandage, 6.0 mm Hg [reference range, 4.5-7.0 mm Hg]) (P=.005). The amplitude of pressure waves during exercise was comparable among most multilayer bandage systems. The pressure loss over time was the smallest in elastic bandages (eg, 4-layer bandage, 6.0 mm Hg [reference range, 0.0-10.5 mm Hg]), compared with short stretch bandages (eg, 3 short stretch bandages, 18.0 mm Hg [reference range, 16.5-20.5 mm Hg]) (P=.005). CONCLUSIONS: Highly elastic multilayer bandage systems showed the smallest pressure loss over several days, but the small pressure decrease when the patient was supine makes them potentially hazardous to patients with arterial occlusive disease. Short stretch bandages and the Unna boot with an inelastic zinc plaster bandage generate large pressure waves while walking and showed a marked pressure decrease when the patient was supine, but they lose a lot of their pressure within the first hours of wear. Multilayer systems composed of short stretch and cohesive medium stretch bandages represent a good compromise between elastic and inelastic bandage systems (moderate pressure loss over time, large pressure decrease on lying down). The clinical effectiveness of the different types of compression still remains to be studied.

PMID: 10890987 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10890987&itool=iconabstr

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Lymphedema Bandages - Supplies and Vendors

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First Aid Direct

http://www.firstaid-direct.co.uk/short-stretch-bandages.htm

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British National Formulary

http://bnf.org/bnf/bnf/current/doc/76235.htm

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Kessler Lerner Lymphedema Services

http://www.kessler-rehab.com/new/LernerServices.asp

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Lymphedema Products

http://www.lymphedemaproducts.com/

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Bandages Plus

http://www.bandagesplus.com/ssen/hartco-ss5.html

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Upper Extremity Bandaging & Self Massage Video

http://www.healthclick.com/lymphvideo_main.htm

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Academy of Lymphatic Studies - Academy Store

http://www.acols.com/store.html

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Allegro Medical

http://www.allegromedical.com/home/default.asp