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Clinical REVIEW
Assessing the effectiveness of
multilayer inelastic bandaging
Hugo Partsch
Multilayer inelastic lymphoedema bandaging (MLLB) applied with a pressure of >45mmHg is the
standard intensive treatment for severe forms of lymphoedema. MLLB consists not only of several
layers but also of different single components whose elastic properties may vary. The combination of
these layers leads to a change in the elastic property of the final bandage, making it more inelastic.
Stiffness, defined by an increase in interface pressure due to an increase in circumference of the
bandaged area, is a more adequate term to characterise these elastic properties.
phase, good bandages should be applied compared the effects of bandages
Key words by well-trained staff for a period of time versus stockings (Badger et al, 2000).
Lymphoedema until no further volume reduction of the The conclusion of this trial was that
treated limb can be obtained. To keep multilayer bandages followed by hosiery
Compression therapy the limb free from oedema, compression gives a greater and more durable limb
Bandages therapy needs to be continued, preferably volume reduction when compared with
Stiffness in the form of compression hosiery. If well- hosiery alone.
fitted compression hosiery is not available,
self-bandaging with elastic material may be Characteristics of multilayer inelastic
an alternative . lymphoedema bandaging (MLLB)
onservative treatment of The main features characterising a
lymphoedema is based on A recently published international compression device are the interface
Cdecongestive lymphatic therapy consensus document on the management pressure and the elastic property of the
(DLT) which consists of compression, of lymphoedema has recommended material.
manual lymphatic drainage (MLD), multilayer inelastic lymphoedema
skin care and exercise. Some schools bandaging (MLLB) exerting a pressure Interface pressure
use the term complete decongestive greater than 45mmHg as ‘standard MLLB are commonly applied with high
physiotherapy (CDP) (Foeldi et al, 2003). intensive therapy’ (Lymphoedema initial pressure. They usually consist of
The most important single component Framework, 2007). more than one component and are made
among these modalities is compression, up of several layers. The padding layer
for which several devices are available, This article will focus mainly on has the main function of reshaping the
e.g. bandages, compression hosiery, multilayer inelastic lymphoedema limb and avoiding proximal constrictions.
velcro band-wraps and pumps producing bandaging and on new ways of assessing After checking the arterial blood supply
intermittent pressure waves. the elastic property of such bandage of the extremity, experienced bandagers
systems. will apply short-stretch bandages with
Bandaging is still the most important considerable tension to achieve an
treatment modality for the initial therapy Evidence-based compression interface pressure of more than 60mmHg
phase, especially in moderate to severe in lymphoedema on the leg and of about 30–40mmHg
forms of lymphoedema, while compression There are only a few randomised on the upper extremity of the arm. These
hosiery is mainly used for maintenance controlled trials (RCTs) available pressures are considerably higher than
therapy after decongestion of the limb. which show beneficial effects from the those achieved with elastic textiles. The
Intermittent pneumatic compression application of compression to reduce common fear that such high pressures
(IPC) can be administered as an additional, the volume of lymphoedematous limbs would not be tolerated is unjustified,
supportive tool. In the initial treatment (Badger et al, 2004). Most of these studies mainly because of the following reasons:
have investigated the additional role of 1. There is an immediate pressure
different supplementary modalities to drop after the application of a strong
Hugo Partsch is Professor Emeritus of Dermatology Medical treat lymphoedema, e.g. MLD or electro- inelastic bandage, even without
University of Vienna, Austria stimulation. Only one single RCT has movement. Two hours after bandage
Journal of Lymphoedema, 2007, Vol 2, No 2 55
Partsch bandaging final C.indd 15 16/9/07 14:59:10
Clinical REVIEW
application the pressure values will Elastic property of the compression material Meditrade, Denmark) and the extension
drop by about 25–50%. This loss The differentiation between elastic and was marked on the bandaged leg and
of pressure is mainly due to an inelastic material is based on measuring measured by a tape. To obtain the same
immediate volume reduction of the the stretch of a bandage caused by an pressure of 45mmHg, the stretch for a
®
lymphoedematous extremity, as can increasing force using extensometer strong elastic bandage (Perfekta strong,
be demonstrated by volumetric devices in the laboratories of the bandage Lohmann & Rauscher, Vienna, Austria)
measurements. When the bandage producers. Usually, elastic bandages are is in the same range of about 40% as
becomes loose it should be reapplied characterised by an extensibility of the for the short-stretch bandage Rosidal
®
to regain its full efficacy. In the material by more than 100%, while K (Lohmann & Rauscher), while the
®
initial treatment phase this may be inelastic bandages are defined by a stretch softer elastic Perfekta super has to be
necessary every day, especially in the lower than 100%. These values of stretch stretched to 137%. This example clearly
presence of massive oedema. cannot be replicated in daily practice, as shows that declaring the extensibility of
2. Inelastic multilayer bandages do not they can only be achieved with extreme a bandage by the manufacturer would
constrict the extremity in the resting forces that will never be applied by only make sense in connection with the
position in a similar way as elastic bandaging a leg. intended pressure range on the leg and
material, due to the property of elastic would therefore be of little help in daily
fibres to regain their unstretched The experienced bandager will not practice.
configuration. However, during the only adjust the tension during bandage
volume changes of the limb during application to the circumference (radius) Another reason why such
muscular contractions, the non-yielding of each part of the leg, but also to the experimental data are of limited
material will create pressure peaks that varying density of the elastic fibres practical value is the increasing use of
exert a rhythmic massage. This specific in each compression product. In the bandage systems consisting of different
physical property can be characterised experiments shown in Figure 2 bandages components.
by the stiffness of the material. of different materials were applied to 10
3. In lymphoedematous limbs the legs with such a tension that in each case When several layers of elastic
thickness of the skin between the a pressure of 45mmHg at the medial bandages are applied, the final bandage
epidermis and the muscle fascia is gaiter area was achieved. The interface will become more and more inelastic
typically increased as well as the pressure was measured using a pressure (Partsch et al, 1999). The four-layer
radius of the cross-section area. Even ® bandage system is an example. Its
monitor (a small Kikuhime probe,
very high pressure exerted during
bandage application will be absorbed
and dissipated by this natural ‘padding
layer’ of the lymphoedematous skin
(Figure 1). According to Laplace’s Law,
sub-bandage pressure is inversely
proportional to the radius of the
curvature of the limb (Thomas,
2003). This means that those parts
of the extremity presenting with
a much enlarged contour need to
be bandaged with extremely high
tension.
A modified intensive therapy
using MLLB with reduced pressure is
recommended in patients with arterial
disease, sensory disturbance, lipoedema,
poor mobility/frailty and in people
with palliative needs (Lymphoedema
Framework, 2007). Bandages exerting
high stiffness are also preferred in these
situations.
Figure 1. Computer tomography showing the cross-section of a leg in a patient with severe lipo-
In general, the sub-bandage pressure lymphoedema. The flame-like structure centre-left is the deposit of a contrast medium injected intradermally
is mainly modified by the force that the (indirect lymphography). The white central parts correspond to the intrafascial muscle compartment; the
user exerts during application and does outer black surrounding is the skin with a massively enlarged layer of subcutaneous fat. When the muscle
not so much depend on the material of contracts during walking, a non-yielding compression bandage will need to be applied with considerable
the bandage. pressure to squeeze out this layer of fluid.
Journal of Lymphoedema, 2007, Vol 2, No 2
56
Partsch bandaging final C.indd 16 16/9/07 14:59:11
Clinical REVIEW
single components are elastic, but the Stiffness sub-bandage pressure when the patient
end-product becomes inelastic. The Stiffness is defined by the increase of stands as a parameter of stiffness is
reason for this change of the elastic interface pressure brought about by an 22mmHg with the inelastic material and
property of a compression device is increase of the leg circumference by 8mmHg with the elastic one.
the infl uence of friction between the standing or walking (Comité Européen
different layers. Adhesive and cohesive de Normalisation European Prestandard, A simple method that can easily
bandages are characterised by a high 2000). be performed in practice has been
degree of friction and will therefore proposed to assess stiffness. A calibrated
behave like inelastic bandages, even This parameter can be assessed pressure sensor is fi xed to the medial
when their fi bres allow high extension. on the individual leg and shows the aspect of the leg about 12cm above
Different padding materials result in a relationship between resting and the inner ankle. This is the area where
fi nal bandage whose elasticity on the working pressure, and is of practical the muscular part of the gastrocnemius
leg will be unpredictable. importance because it describes the muscle changes into the tendinous part,
deciding parameters of good tolerability showing the most extensive changes in
With the use of the terms (low resting pressure) and strong local curvature and leg circumference
multilayer, multicomponent or effi cacy (high working pressure) of a by changing the body position between
adhesive and cohesive bandages, it compression device (Partsch, 2005). supine and standing. The difference
is questionable whether the terms between the interface pressure in
‘elastic’ and ‘inelastic bandages’ still When the muscle contracts, inelastic the standing and in the lying position
have any meaning. material will not give way and will (mmHg), called static stiffness index
produce a higher increase of interface (SSI), is a valuable parameter for the
The terms ‘elastic’ and ‘inelastic’ pressure than elastic, yielding material. stiffness of the compression system
are based on the physical property The pressure increase may exceed (Partsch et al, 2006).
tested in a laboratory and should only 20–50% of the resting pressure, thereby
be used in connection with single exerting a considerable ‘massage effect’. Another method showing an
bandages. When it comes to describing excellent correlation with the SSI is
the properties of bandage systems Figure 3 gives an example comparing to measure the difference between
composed of different materials on the the pressure exerted by an inelastic and resting pressure and working pressure
leg, it is more reasonable to talk about an elastic bandage, both applied with the during dorsifl exion. One important
lower or higher stiffness. same resting pressure. The increase of drawback of this method is that it is
diffi cult to reproduce exactly due to the
different degrees of dorsifl exions and
Extension (%) to achieve 45mmHg at B1 the restricted ankle mobility in some
n 10 patients.
��� =
��� ��������� ������� The most appropriate way to
quantify stiffness would be to measure
��� dynamic stiffness during walking.
Unfortunately, this method requires
��� sophisticated instrumentation and
� therefore cannot be used in routine
�� clinical practice (Stolk et al, 2004).
��
Several authors have shown that an
�� increase of the sub-bandage pressure
� of more than 10mmHg describes high
Rosidal Perfekta strong Perfekta super stiffness, while a pressure increase of less
��� �������� ��������
than 10mmHg characterises bandages
does not separate inelastic from elastic and stockings with low stiffness (Hafner
et al, 2000; Partsch, 2005). Although this
Figure 2. Different compression bandages were applied in 10 volunteers with a tension that resulted in a could be shown with several pressure
pressure of 45mmHg above the inner malleolus (measuring point B1, the site where the muscular part of transducers and on different areas of
the medial gastrocnemius muscle changes into the tendinous part) and the extension of the materials was the gaiter area, it has to be stressed that
measured in relation to the unstretched bandages (%). The median values for the extension were 39% for the dimensions of the pressure probes
® ® and the curvature of the measuring
the short-stretch bandage Rosidal (Lohmann & Rauscher) and 41.5% for the long-stretch Perfekta strong
® area on the leg have a considerable
(Lohmann & Rauscher). Another elastic long-stretch bandage (Perfekta super) had to be stretched by 137%
(p<0.001) to achieve the same interface pressure. This experiment shows that the declaration of the extension infl uence on the calculated stiffness
of a bandage by the producer based on in vitro measurements does not give a clinically useful information. values. When a leg with a large diameter
Journal of Lymphoedema, 2007, Vol 2, No 2 57
Partsch bandaging final C.indd 17 16/9/07 14:59:11
Clinical REVIEW
Sitting Standing Sitting Standing Lymphoedema patients need
continuous compression day and night,
100 100 at least during the initial phases of
90 90 treatment. For this purpose, inelastic
80 80 bandages and compression systems
)
g with high stiffness are superior to elastic
H 70 70
m bandages since they exert a lower
m Sitting dorsiflexion Tiptoeing
(
60
e 60
r resting pressure which will be tolerated
u
s
s
e 50 50 also in the supine position.
r
P
40 40
Sitting dorsiflexion Tiptoeing Oedema reduction seems to be
Figure 3. Measurement of the interface pressure exerted by an ‘inelastic’ short-stretch bandage (left) and by an more a question of exerted pressure
‘elastic’ long-stretch bandage (right) in the supramalleolar region of two legs. The resting pressure in the sitting than of the material used. Higher
position was about 50mmHg for both bandages. During dorsiflexions pressure peaks up to more than 80mmHg compression pressure leads to a faster
are achieved by the inelastic, and up to 55mmHg by the elastic material. The pressure increase by standing volume reduction of the swollen limb
up was 22mmHg with the inelastic, and 8mmHg with the elastic material. The pressure amplitudes during than lower pressure. Again, high pressure
movement exert a ‘massage effect’ and are much higher with the inelastic than with the elastic bandage. produced by inelastic material is better
tolerated than the pressure achieved by
elastic bandages.
is measured with a large pressure probe, rather poor. This is especially true in
the pressure increase by standing up lymphoedema where objective findings Some authors have experienced
and by walking will be lower than in a are more difficult to prove than in a worsening of lymphoedema when
patient with a small leg circumference, venous pathology. However, some using elastic sleeves (Lerner, 2000).
in whom a small sensor is positioned hypothetic arguments favouring material A guideline of the German Society
over the protruding tendon. Particularly with high stiffness will be outlined. of Lymphology strictly recommends
in patients with lymphoedema of the against the use of compression
lower extremities, the sharp cut-off We need to consider the main garments in the initial treatment phase
line of 10mmHg differentiating more features that are different in lymphatic in order to avoid ‘chronification due to
or less stiff compression bandages may disease compared with venous an under dosed therapy’ (Foeldi et al,
not be valid in certain cases. Reliable pathology when choosing a specific form 1998).
comparisons will only be possible when of compression therapy.
testing different compression devices by Compression will always induce
using the same sensor on the same site Table 2 shows some principal some shift of tissue fluids into those
(Partsch et al, 2006). differences concerning compression areas of the extremity that are not
therapy in venous and lymphatic disease. covered by the compression device.
Which materials provide high stiffness? In fact, venous and lymphatic pathology This may cause swelling of the toes
High stiffness defined as tolerable show considerable overlapping, especially or fingers and accumulation of fluid
resting pressure and highly effective in the area of microcirculation and fluid in the region of the groin or the axilla.
working pressure can be achieved by exchange. The schematic differentiation As long as the lymphatic drainage in
short-stretch bandages, multicomponent presented in Table 2 should mainly serve these areas is intact, such as with pure
multilayer bandages and by Velcro-band as a guide for a more detailed discussion. venous oedema, this increase of fluid
devices. This is also true for elastic
stockings applied over each other
(Cornu-Thénard et al, 2007; Partsch
et al, 2006). Adhesive and cohesive Table 1
materials increase stiffness. Table I gives a
short overview. Overview of low and high stiffness compression materials
Rationale for using inelastic multilayer Low stiffness High stiffness
bandages in lymphoedema 8 Compression stockings (single layer) 8 Rigid bandages (e.g. zinc paste)
Most experts experienced in 8 Velcro-band devices
conservative management agree that 8 Pumps
multilayer short-stretch bandages are
preferable for the initial treatment of 8 Single component elastic bandages 8 Short-stretch bandages
lymphoedema. 8 Adhesive, cohesive bandages
8 Multilayer bandages
Our knowledge of the mechanisms
of action of compression devices is
Journal of Lymphoedema, 2007, Vol 2, No 2
58
Partsch bandaging final C.indd 18 16/9/07 14:59:12
