A contextual view of compression bandaging for lymphoedema
Christine Moffatt CBE, FRCN, PhD, MA, RGN, DN
Professor of Clinical Nursing, Nottingham University, Nurse Consultant, Chair, International Lymphoedema Framework
The cornerstones of lymphoedema management as outlined in the literature  include:
- manual lymphatic drainage (MLD)
- compression therapy
- exercise and skin care
Compression bandaging plays a central role in the management of all forms of chronic oedema and lymphoedema .
Problems of definition
International variations in the use of the terms to describe this multi-modal treatment exist. Formerly, the terms complex decongestive treatment (CDT), complex physical therapy (CPT), or complex decongestive physiotherapy (CDP) were used. International consensus in 1998 changed this terminology to decongestive lymphatic therapy (DLT), as this clarified that treatment involved the lymphatic system. Terms such as complex or complete were also thought to be subjective and confusing and were therefore abandoned. More recently, the first edition of the International Lymphoedema Foundation’s Best Practice Document  adopted the term intensive treatment. The reason for this change was the recognition that treatment could involve other modalities than those traditionally described and that the term DLT was too restrictive.
Despite the changes in terminology, there continues to be wide variation in the performance of MLD techniques, use and application of compression systems, and exercise and skin care regimens. This contributes to the lack of evidence on the effect of DLT and the challenge of comparing studies that use DLT in many different ways. The heterogeneity of the population requiring DLT is a further challenge in evaluating the outcomes of treatment.
Recent systematic reviews show that bandaging and compression hosiery when used in combination, are more effective at reducing and maintaining limb volume over six months than using hosiery alone . The systematic reviews call for improved clinical trials and the ability to understand the relative contribution of the different aspects of treatment. To date, very little research has been undertaken on the different combinations of bandages or different bandage application techniques, and practice is largely based on tradition and clinical experience.
Understanding when bandaging is used
While it is recognised that multi-layer bandaging is used during a period of DLT (intensive treatment), it may also be used as part of long-term management in certain groups who cannot wear compression hosiery. Bandaging may be very effective in aiding symptom control in patients with cancer-related lymphoedema and frail patients with complex medical problems . Patients may also choose to self-bandage as part of their long-term management plan.
It is essential that practitioners understand how application techniques can affect the performance of bandage systems. Traditional approaches to multi-layer lymphoedema bandaging use inelastic bandages over padding or foam layers. Technological advances in compression materials are influencing our understanding of features required in an ideal compression system, and new compression devices are emerging that bridge the gap between bandaging and use of compression hosiery.
Understanding mode of action
The mode of action of compression in lymphoedema management has been poorly understood and has relied heavily on literature from venous disease . Recent research is beginning to unravel the mechanisms of action in compression and will therefore allow greater clarification of the optimal compression profiles for patients with arm and leg oedema [6,7]. Traditional methods of application involving extensive padding are also being reconsidered with the focus on increasing patient function and overall mobility. Underpinning principles such as the use of Laplace’s law are being challenged, as methods of application show that appropriate gradients of pressure are rarely achieved and extensive padding reduces the overall effectiveness .
Outcomes of compression bandaging
The primary outcome in most compression studies in lymphoedema is change in volume at the end of treatment. However, there is no internationally agreed definition of what an ideal volume reduction should be, and different methods of measuring limb volume add to this complex debate. Other outcomes may be more important to heath care systems than the change in volume. These include:
- the cost-effectiveness of care through improved clinical outcome and appropriate use of health resources
- the potential to reduce episodes of cellulitis requiring hospitalisation
- a reduction in patients requiring expensive episodes of DLT
Improved clinical trials in compression bandaging must address these issues and implement the agreed international standards for undertaking such studies . This includes the ability to understand the ‘dose’ of compression being used throughout a trial using sub-bandage pressure measurement to define stiffness. This will help to define which bandaging systems are most appropriate for different patient groups. It will also help to define the optimum length of treatment. Current evidence suggests that the majority of fluid is removed during the first treatment episodes; however, many patients require much longer treatment and there are no agreed standards of how long bandaging should be performed or the criteria for when it should be stopped .
Health system challenges
Lack of reimbursement for lymphoedema care due to the dearth of research is a major international challenge and currently reduces access to appropriate compression bandaging in many parts of the world. In developing countries, the cost of bandaging is often prohibitive, and resource poor countries urgently need low cost and effective compression bandages. They also face the additional challenge of lack of access to health care and approaches that involve self care and involvement of family and the local community have much to teach the western world.
Management of patients with complex lymphoedema requires highly skilled, specialist practitioners. Patients with late-stage lymphoedema may have extreme limb distortion requiring adaptation of both the materials used and the application technique . Morbid obesity is on the increase and it is suggested that 80% of obese people will suffer with lymphoedema, which is generally complex to bandage . Research in the United Kingdom (UK) and Canada show that many lymphoedema services are treating more complex patients with multiple co-morbidities and continue to be referred patients who have not been diagnosed or offered treatment .
Current approaches to DLT are labour intensive, requiring daily treatment for several weeks. Practitioners frequently have to modify treatment to meet the complex clinical and psychosocial needs of patients. A major frustration for both professional and patient is maintaining the improvement during DLT once this has finished. Rebound oedema is a common and complex clinical challenge that requires effective compression solutions.
Traditional bandaging used in DLT requires considerable commitment from the patient to attend for daily treatments. Patients recognise the effectiveness of the treatment but many find it restrictive influencing their work and social activities . Immobile patients often have difficulty attending for bandaging and require help at home to accommodate the compression when it is applied. A recent clinical trial using a new compression method (Coban® 2 system) showed that the most effective clinical and cost outcome was achieved in patients being seen twice weekly . However, the bandages used maintained their performance over a number of days. The same study showed that patients had improved function when compared to a traditional inelastic system.
Younger patients are requesting the use of bandages they can safely apply themselves. Lack of access to health care support will require the lymphoedema community to develop and evaluate effective compression systems that can be safely used in the patient’s home. New compression wraps such as CircAid® and Juxtafit™ can be applied by even the most immobile patient and can be used in combination with bandaging or compression hosiery with good effect .
These recommendations are based on physiological principles and the current evidence base. While this article focuses on one element of DLT, compression bandaging, it is essential that all other components of care are effectively delivered to patients in whom there is a clear clinical diagnosis and treatment plan.
- Compression is the single most important component of decongestive lymphatic therapy (DLT)
- Inelastic lymphatic bandages are mainly used for intensive therapy in the initial treatment phase. In combination with exercises they exert a massaging effect with every muscle contraction. More stretchable material which is rather available in several parts of the third world will loose its elasticity by repeated washing and will obtain inelastic properties
- Good bandages should not impede the functionality and need to be adequately trained. Too much padding is often counterproductive
- The mode and strength of compression should be adjusted to the individual needs
- Skin care plays an essential role in preventing local complications and (recurrent) infections (cellulitis)
- In palliative patients the treatment goals need to be redefined and compression should be adjusted accordingly
- In developing countries compression therapy is still underused, mainly because due to high costs and lack of trained staff