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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 ...

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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
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...Clinical review assessing the effectiveness of multilayer inelastic bandaging hugo partsch lymphoedema mllb applied with a pressure mmhg is standard intensive treatment for severe forms consists not only several layers but also different single components whose elastic properties may vary combination these leads to change in property nal bandage making it more stiffness dened by an increase interface due circumference bandaged area adequate term characterise phase good bandages should be compared effects key words well trained staff period time versus stockings badger et al until no further volume reduction conclusion this trial was that treated limb can obtained keep followed hosiery compression therapy free from oedema gives greater and durable needs continued preferably when form if alone tted available self material characteristics alternative onservative main features characterising based on recently published international device are cdecongestive lymphatic consensus document man...

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