Lymphedema banding is one of the most powerful components in the treatment process. When a good bandage is applied, it will function as a custom-made compression garment, each and every time. While the extremity is reducing in size, the bandage is adapting to the new dimensions. A pre-made elastic garment will never have this adaptability.
It is said that the compression bandage contributes to approximately 50% of the reduction achieved with CDT. With this in mind, it is clear to proficiency in the bandaging techniques is crucial to achieve the best possible outcomes.
The lymphedema compression bandage is best described as a multi-layered low-compression bandage. The compression is achieved by the thickness of the bandage, not by the tightness. The bandage will easily consist of 8-10 layers, especially more toward the periphery. The layers may consist of different materials, each with their own distinct function. They can be distinguished in 3 basic layers. These are the absorption, equalization and the compression layers.
The absorption layer is in direct contact with the skin. Its main function is to absorb perspiration and to be a barrier between the skin and the layers of the bandage and thus minimizing irritation and increasing the comfort.
Materials of the absorption layer are preferably cotton-based and washable. Frequently used materials include Stockinette tubular or flat bandages without significant compression or Tubigrip tubular bandages with some compression. The advantage of tubular bandages is the ease of donning/doffing, but the fit may not always be optimal. The advantage of flat, single layer material is the more custom fit, but it requires about two layers for optimal coverage and it is slightly more complex to apply, especially with self-bandaging. Most of this material is washable and reusable.
This layer is placed over the absorption layer and consists of materials that aide in pressure distribution. If used correctly, this layer can be used to equalize, focus or relieve pressure at certain areas within the bandage. This material can be foam, cast padding or a combination of both. Foam is much more durable than cast padding, but it adds significant thickness to the bandage. Cast padding only last 3-4 applications, but it adds significant comfort to the bandage. The ideal solution is a combination of cast padding with foam inserts.
Foam inserts can be used to add compression to an area such as a fibrotic patch or to protect an area from over-pressure such as the shin. Another use can be a foam insert with a cutout to protect any open wounds in the extremity. If no foam is available, pads can be made by using multiple layers of the cast padding material. If cost prohibits the purchase of foam, consider foam rubber packing material.
To get an even layer of cast padding, use at least 2 layers throughout the bandage. With foam one layer throughout is sufficient.
This layer is giving the actual compression on the extremity. It consists of several layers of short-stretch bandage material. Brand names include Comprilan, Conco, Rosidal-K, and many others. Short stretch bandages have only about 20% stretch, compared with up to 100% of elastic bandages such as Ace.
To secure the bandage in place tape is recommended over the elastic clips that are often supplied with the bandages. These clips have sharp points at the edges that may cause small wounds that will worsen the condition. With normal use one strip of paper-tape for each layer and 4-5 strips for the final layer will be sufficient. If the patient has no paper-tape available, masking tape can be used. Avoid using silk-tape, since the heat of the bandage will soften the glue and make for a very sticky bandage after several uses.
The cost of the lymphedema bandage can become quite high. The materials for the absorption layer are quite cheap, the equalization layer materials vary from cheap (cast padding) to more expensive (foam rolls), but most of the cost will be in the compression material. Depending on the size, manufacturer and vendor these will vary from $5 to $10 per roll. Depending on the size of the extremity and the extend of the bandage 4 to 15 compression bandages may be used leading to a cost from $25 to $125 per bandaged extremity! Insurance companies rarely reimburse for these costs.
Depending on the setting different solutions are used to offset these costs. One solution is to absorb the cost of the bandage materials into the cost of the treatments. Another solution used is to give the patient a "shopping list" of the required materials and have them buy the supplies at a recommended vendor. The first option may work better for clinics with a large volume of low-income patients, but the second option tends to facilitate more responsibility from the patient since they will have to purchase more materials if bandages get lost or damaged.
The absorption layer and the compression layer materials are washable. Use a gentle detergent, but no Woolite, since this affects the elasticity in the bandage. Let the bandages air dry, but keep in mind that it will take 2 to 3 days for them to dry completely. This means that the patient may need a second set of bandages to wear while the first set is in the wash.
Since the compression in the lymphedema bandage is achieved by resisting the muscle pump, it is essential to not apply the bandage too tight. Upon completion, the compression bandage will have a consistency somewhere between a cast and a regular bandage. This can be easily checked by tapping on the bandage. It should have a firm consistency with minimal give. When completed, the compression of the bandage should be within the 30-40 mmHg compression range.
As with most things in life, good preparation makes for an easy task and so does practice. Have all supplies ready and within range prior to start bandaging. This means having all the bandages out of the box with all clips removed, tape pre-cut and ready to go and if required any wound dressing materials ready for use with all packages opened. If the compression bandage material has already been used, make sure that it rolled up tightly. If the roll is too loose, the bandage most often will be applied too tight. A tightly wrapped bandage roll will enable easily rolling off, maintaining full control over the bandage application. Practice the application of the bandage frequently, as this will increase the speed of applying it and with that the consistency of compression with each application.
In the clinic the use of a high-low table and bolsters will further increase the ease in applying the compression bandage.
The techniques described on the following pages are based on several years of experience with very large patients with a very limited support system. It is not always consistent with bandaging taught in certification courses. The modifications have been made to increase mobility of the patient by freeing up the main joints and to increase the endurance of the bandages.
The lower leg bandage is indicated on patients who are referred for lymphedema treatment but have mainly a venous insufficiency problem. It is easy to apply with a limited amount of bandages and this can be easily taught to a partner or caregiver. It will maintain excellent mobility for the patient since it is not affecting the knee joint. It is however essential to monitor the patient closely for any swelling starting right above the proximal edge of the bandage. This is why this is mainly used while the patient is still in treatment. It will usually require 4-5 rolls of compression bandage to effectively bandage the lower leg. All bandage techniques demonstrated assume no wounds on the extremities. Make sure to check for proper circulation in the toes throughout the application of the bandage. If the toes turn purple or cold, start over again.
Cover the lower leg with Stockinette, either tubular or flat. When using the flat material, use approximately 2 layers to cover the lower extremity. Have some extra overlap over the toes and over the knee. At a later stage this can be folded back for a more finished look.
Cover the lower leg with at least 2 layers of cast padding, applied in a spiral motion over the foot, a figure-8 over the ankle and a spiral motion over the rest of the lower leg, to just underneath the patella.
Anchor the smallest of the compression bandage (6cm width) over the fore foot. Next bring it behind the heel. Circle the fore foot again and go back behind the heel. Repeat this a total of 3 times. After the third time, come up from behind the heel and finish rolling the bandage over the lower leg with a herringbone technique. At this time make sure not to cover the anterior ankle, since having too much material will limit ankle motion and can be a cause of irritation. On the lower leg use a 2/3rd overlap, meaning that only 1/3rd of the bandage will stick out from underneath.
This step needs to be used for patients with more severe edema with significant foot involvement. For patients with more venous edema it can often be omitted. Adding this step will significantly thicken the bandage over the foot and therefore make it much harder for the patient to fit into a regular shoe. Wearing a regular closed shoe will act by itself as a compression factor.
Start by circling the ankle in three steps, still ensuring not to cover the anterior ankle. After this, continue the bandage on the lower leg with the herringbone technique, maintaining 2/3rd overlap.
For this step use on size up, the 8cm wide bandage. Anchor at the forefoot, just as in step 3 and spiral up over the ankle. Make sure to only use 2 layers over the anterior ankle. Continue on the lower leg with a herringbone technique, maintaining 2/3rd overlap.
Start just above the ankle with the 10cm bandage, using the herringbone and while maintaining 2/3rd overlap.
Feel the bandage for firmness. Where the bandage feels softer to touch is where the next roll will start. Again, use a 10cm bandage, using the herringbone and maintain the 2/3rd overlap. This bandage should end right underneath the patella. If not, add another bandage roll to complete the compression bandage. Secure the bandage with 4-5 strips of tape.
To finish the bandage off, the absorption material can be folded back and either taped to the bandage or folded underneath the last layer of compression material.
If the extremity is wide or tall, use larger size bandages to accommodate the patient. For very large extremities use double-length rolls of compression bandages. These are available from different manufacturers in the wider sizes (10 and 12 cm).
For patients with severe toe or finger involvement it may be necessary to also wrap these individually. Most authors use one or more rolls of gauze bandage for this purpose. Experience has shown that products such as Coban can be an excellent substitute for this. Cut the Coban in ¼ inch strips and gentle wrap these around the toes or fingers. The main advantage of using this material is that it significantly reduces bulk, which can be especially irritating between the toes.
The full leg bandage described here various from the usually described bandages in that it is a two separate component bandage. The lower part is the lower leg bandage as described above. The justification of this approach is the following. The thigh is significantly softer that the lower leg. Reduction in edema will result in girth reduction at a much higher pace in the thigh than in the lower leg. The bandage will fall apart first at the thigh. Most often the lower leg part will remain intact long after the thigh part has fallen apart. Having a one-piece bandage would mean correcting the entire bandage when the thigh part loosens up. The other justification is that a one-piece bandage significantly reduces the mobility of the knee. The two-piece approach will facilitate activity from the patient, which will help promote circulation.
Apply the absorption layer material on the thigh, partially overlapping the lower leg bandage.
Apply the equalization material, partially overlapping the lower leg bandage. If desired, additional padding may be added behind the knee joint.
Apply the compression bandage to the thigh, starting just above the patella, using the herringbone technique. Depending on the size of the leg, use a 10 or 12 cm wide bandage. If the leg is very large, use a double-length roll. To help shape the lower part of the thigh, a slight tuck can be used at the end of each turn. Make sure not to over tighten the bandage.
This part will connect the lower leg portion with the thigh. First anchor a 10 cm bandage distal from the patella. Next spiral it relatively loosely over the knee joint with 3/4th overlap. Once above the knee joint, continue with the herringbone technique at normal tension. The loose spiral will allow for knee mobility.
Apply this layer identical to the layer in step 9. Start right above the patella again and use the herringbone technique.
Continue with bandaging the thigh with herringbone technique and 2/3rd overlap until the top of the thigh has been reached. Start new layer where the bandage starts feeling softer. Finish the bandage off by folding back the top and taping it off.
The above steps are suggestions for a leg with normal proportions. When needed, modify the bandage to accommodate for irregular shapes by using more padding and foam inserts, but keep the same principles in mind.
The upper extremity compression bandage is similar to the lower extremity bandage, except for the hand technique. An important focus of this bandage is often to give sufficient compression on the dorsum of the hand while maintaining hand dexterity in order not to render the hand useless.
Apply thin (1/4") strips of Coban® as an anchor around the mid-hand. Next apply strips around each finger in a spiral way with some overlap, starting at the nail bed working toward the mid hand and anchoring the end onto the anchors. When all fingers are covered, close up any open areas with additional strips. Make sure not to pull the Coban® too tight when applying it.
Apply a layer of stockinette over the arm starting at the mid-hand up to the axilla. When using tubular material make a small cutout for the thumb.
Apply the padding material in a spiral fashion with 50% overlap. Additional material may be added to protect the inside of the elbow.
Start with a 6cm compression bandage around the hand an wrist, leaving the thumb and finger open. Apply 3 layers of material. Continue up to the forearm with a herringbone technique.
Apply an 8 cm bandage starting at the wrist with a herringbone technique up to the fore-arm.
Apply additional bandages if needed until just below the elbow.
Anchor a 10 cm bandage just below the elbow. Then loosely spiral it over the elbow joint with a ¾ overlap. Once past the elbow joint continue up the upper arm with a herringbone.
Add additional bandage to the upper arm until the bandage is firm up to the axilla.
When indicated and the patient is deemed capable of doing so, they should be trained in self-bandaging. Of course family members can also be trained in applying the bandages. It is most important to educate the patient about the importance of bandaging, proper technique and care of the bandage materials. Even though it seems complicated and frustrating in the beginning, give the patient or family member positive reinforcement and convince them that any bandage they will apply will be better than wearing no bandage at all.
Take sufficient time during the treatment sessions to practice the bandaging techniques, as proper bandaging at home will help with hygiene and treatment outcomes. It may be good to have several sets of practice bandages in the clinic to avoid wasting time re-rolling them. This may also be a good time to have the patient considering the purchase of a bandage roller, a simple and affordable (approx. $15) tool that will significantly reduce bandage-rolling time.