The Benefits of Daily Use of Compression Therapy for Lymphedema
lymphede...@gmail.com
by Joachim E. Zuther
Compression Therapy
Compression therapy is an essential part of lymphedema management.
Without the benefits provided by either specialized short-stretch
bandages or elastic support garments, successful treatment of
lymphedema would be impossible. For good patient compliance - another
important part in lymphedema management - it is necessary to
understand how compression therapy affects lymphedema and how bandage
materials and compression garments complement each other.
Effects of Compression Therapy on the Tissue Pressure
Tissue pressure plays an essential role in the exchange of fluids
between the blood capillaries and the tissues. The volume of fluid in
the interstitial tissues, external forces (compression, hydrostatic
pressure) as well as altitude have an effect on the tissue pressure.
The onset of lymphedema is caused by a reduced transport capacity of
the lymphatic system resulting in the inability to respond to an
increase of lymphatic loads. This causes water and protein to
accumulate in the interstitial tissue. The important aspects in the
treatment of lymphedema is to reduce the volume of fluid that leaves
the blood capillaries via ultrafiltration and to also improve the
reabsorption of these fluids back into the venous end of the blood
capillaries.
Increasing the tissue pressure by the skillful application of short-
stretch bandages or wearing compression garments will achieve this
desired effect. The higher tissue pressure will reduce the amount of
fluid leaving the blood capillaries and increase absorption of tissue
fluids via the venous end of the blood capillaries and the initial
lymphatic system.
Effects of Compression Therapy on the Venous and Lymphatic Return
The activity of skeletal musculature is an important factor in the
return of fluids within the venous and lymphatic system. Together
with other supporting mechanisms the muscle pump activity propels
these fluids back to the heart and ensures an uninterrupted
circulation. In order for these systems to work sufficiently, good
joint movements and normal tissues are essential. In lymphedema the
elastic fibers of the skin are damaged and overstretched and thus
unable to effectively support the muscle and joint pumps in the
return of tissue fluids. The damaged skin elasticity becomes apparent
especially following decongestion of lymphedema; the reduction of
edema volume and the elastic insufficiency of the skin make refilling
of the limb with edema fluid quite easy. The application of external
compression compensates for this diminished tissue pressure and thus
improves the efficiency of the muscle and joint pumps and prevents
the re-accumulation of fluid.
Effects of Compression Therapy on Accumulated Connective Tissue
The accumulation of protein rich fluid in lymphedema leads to tissue
proliferation, which causes a progressive hardening of the connective
tissue in the affected areas; this change in the quality of the
connective tissue is also referred to as lymphostatic fibrosis. Good
lymphedema management includes the softening of these proliferated
tissues. This can be achieved with the use of special foam materials
within the compression bandage. The increase in localized pressure
achieved with these foam pads in combination with muscular activity
results in a breakdown and softening of the fibrotic tissues.
The Role of Bandages and Compression Garments
Compression therapy in lymphedema management is achieved by
specialized compression bandages or compression garments (or the
combination of both).
Compression bandages are typically used in the first phase of
Complete Decongestive Therapy (CDT). The goal in this phase is to
decongest the swollen limb as much as possible by the combination of
Manual Lymph Drainage, a customized exercise program and the
application of special short-stretch bandage materials between the
treatments.
The difference between regular bandages ("ace" bandages) and short-
stretch bandages lies in the working and resting forces generated by
these two forms of compression.
Working pressure refers to the resistance the bandage creates against
muscle and joint movements. The multi-layered application of short-
stretch bandages provides an excellent counter pressure during
movements and exercises, which is paramount to increase lymphatic and
venous return and to prevent re-accumulation of evacuated edema fluid.
Resting pressure is the amount of pressure the bandage exerts on the
tissues during rest. The fabric of short-stretch bandages contains
minimal elasticity, thus preventing a tourniquet effect on the
extremity at times of inactivity.
The relatively high working and low resting pressure of short-stretch
bandages in combination with padding, which is achieved with soft
foam or special non-woven synthetic bandages, creates a soft "cast-
like" environment promoting decongestion.
The fabric used in "ace" bandages contains high elasticity. This
results in low working pressure and the possibility of a tourniquet
effect on the extremity during rest; the use of high-elastic or long-
stretch bandages in lymphedema management is therefore absolutely
contraindicated.
Once the extremity is decongested, the patient wears compression
garments during the day. In some cases it may be necessary for the
patient to additionally apply bandages during nighttime. Typically
patients remove bandages upon awakening in the morning and apply
either a compression sleeve or stocking to the extremity. While
maintaining the limb size, the compression garment allows for a non-
bulky and natural limb contour. Compression garments also provide
a "built-in" compression gradient; the gradual decrease in
compression along the limb (lowest in areas closer to the trunk)
provides the basis for efficient drainage of fluids from the
extremity.
In order to achieve best results, garments must be worn every day and
replaced after six months. Specially trained personnel should take
the measurements for these elastic support garments; incorrectly
fitted sleeves or stockings will have negative effects. The type of
garments (round or flat-knit style) and the compression class depends
on many factors such as the patients' age and the severity of the
swelling. For upper extremity lymphedema, compression classes I (20-
30 mm/Hg) or II (30-40 mm/Hg) are typically used; for lymphedema of
the lower extremities, compression classes II, III (40 - 50 mm/Hg) or
IV (>50 mm/Hg) are suitable. In some cases it may be necessary to
apply compression class III to an upper extremity or an even greater
compression than class IV to a lower extremity lymphedema. This can
be achieved by either wearing two stockings on top of each other, or
by the application of short-stretch bandages on top of a stocking.
The Benefits of Compression Therapy
It is of importance to understand that there is no cure for
lymphedema. If lymphedema is present, the lymphatic system is damaged
and unable to function properly. Patients will always have to
practice preventive measures as ordered by the physician or the
lymphedema therapist, in order to avoid aggravating the lymphedema -
lifelong.
Lymphedema is a progressive condition, which tends to get worse
without proper treatment and management. Complete Decongestive
Therapy, that is, the combination of Manual Lymph Drainage, skin
care, exercises and compression therapy administered by a trained and
certified therapist is in the majority of cases effective in removing
the swelling and bringing the extremity back to a normal or near
normal size. In order to maintain - and often to further improve this
reduction - it is absolutely necessary that compression garments be
worn daily.
The additional application of a light bandage at night using short-
stretch bandages becomes necessary if lymphostatic fibrosis is still
present post reduction or if the extremity tends to increase in size
during the night.
Lymphedemateous skin tends to be very dry; compression garments and
bandages dry the skin even more. Dry skin is more susceptible to
infections, which makes it necessary to moisturize the skin regularly
with a low-pH lotion (preferably fragrance and alcohol free).
Lymphedema Requires Lifelong Care
It is understandable that the lifelong care and management of
lymphedema can be frustrating at times for the patient, but
lymphedema is not the only condition requiring lifelong maintenance.
For example, patients with diabetes are required to take daily
insulin injections/medications to manage their insulin levels. Once
the insulin levels are controlled, the diabetic must not stop taking
the medications.
As with patients suffering from diabetes, lymphedema patients must
continue daily and lifelong management strategies to maintain
improvements gained from Complete Decongestive Therapy. Without
compression and proper care there is a high chance that complications
from lymphedema will develop again. Lymphedema Defined
Lymphedema can be defined as high-protein edema and is classified as
either primary or secondary; lymphedema may be mild, moderate or
severe, affects most often the extremities but may also be present in
other parts of the body. If left untreated chronic alterations
(lymphostatic fibrosis) and frequent cellulitis attacks are common
additional problems.
Although lymphedema may be reduced to a normal or near normal size
utilizing proper treatment techniques, the lymphatics are never
normal again once lymphedema is present. The affected body part is
always at risk of developing more lymphedema.
--------
About the Author:
Joachim E. Zuther
Joachim E. Zuther is a certified instructor in Manual Lymph Drainage
and Complete Decongestive Therapy. He is the founder and director of
the Academy of Lymphatic Studies, and the author of the recently
published textbook Lymphedema Management (Thieme Medical and
Scientific Publishers, NY - ISBN: 1-58890-284-6). He is also an
active member of the International Society of Lymphology and the
German Society of Lymphology. The Academy of Lymphatic Studies offers
certification classes in Lymphedema Management throughout the year in
the U.S. Mr. Zuther can be reached at 772-589-3355
----------
Lymphedema People
http://www.lymphedemapeople.com