Lymphatic drainage Bascharage

The French language distinguishes between two different words: “Compression” and “Contention”. These two words are by no means synonymous. These are two initially opposed physical principles. Their physiological effects differ considerably depending on whether the limb is at rest or under muscular contraction. The English language, which is the basis for scientific articles, makes no such distinction when describing the various decongestion devices. Only the word “compression” is translatable (Harrap’s dictionary). Using one for the other sometimes leads to major misunderstandings.

Contention-compression (CC) is essential for treating lymphedema, reducing its volume and maintaining its reduction. It is the subject of a broad professional consensus, but different modalities and adaptations condition the benefit of this treatment.

However, the academic distinction between short-stretch (“non-elastic”) and elastic bands is sometimes theoretical. Very short-stretch bands are often positioned on a foam or cotton underlay, which they compress, providing unexpected compression at rest. Conversely, the use of low-stretch, overlapping elastic bands creates a restraining effect.

Wearing a sleeve or stocking alone is not the answer to all indications. The experience of physiotherapists, who prescribe and apply it, should enable CC to be chosen, customized and regularly adapted to optimize its effectiveness.

Reducing bandage techniques

There are a number of different modalities, depending on the author and the clinical aspect. They always follow the same principles: they superimpose very short-stretch bands to give the bandage rigidity, and more or less long-stretch elastic bands to provide compression.

This combination of rigidity and elasticity is what makes this technique original and effective. For lymphedema decongestion, rigidity takes precedence over elasticity. Elastic bandaging alone is not always enough to reduce lymphedema.

The non-elastic band exerts a low resting pressure. During activity, the inextensible nature of the band causes edema to be compressed between the contracting muscle and the external fascia. The pressure is then very strong and decreases as soon as the muscle relaxes. It is the alternation of these pressures that represents the edema-reducing component.

This bandage should only be worn in conjunction with physical activity. This can be more or less intense, with no risk of aggravating the lymphedema.

The elastic band ensures a resting pressure that depends on the degree of elongation. Macroscopically, this compression acts mainly on veins whose caliber is reduced. Blood flow is accelerated and pressure inside the vessel is reduced.

At microcirculatory level, this pressure improves capillary-veinular resorption and limits filtration. Some elastic bands have the property of being elastic in both directions, allowing them to adapt to the shape of the limb to be compressed.

Thanks to the addition of foam or cotton, the stresses exerted by the bandages are distributed harmoniously, with the aim of “filling the hollows and reducing the bumps” in a limb segment. It’s a good idea to aim for a cylindrical or frustoconical shape. These are daily actions, reviewed and readapted to each modification and reduction in the edema being treated. Depending on the size and consistency of the oedema, two or more strips may be required, one on top of the other.

The choice of a bandage type for a patient is not necessarily definitive, nor is it unique.

When should bandages be used?

Bandages are used during attack treatment to reduce the fluid phase, or during maintenance treatment to reduce a punctual increase.

During initial treatment, they are replaced at each session and are permanently adapted to the volume of the limb. They are stored 24 hours a day. The compression setting must be carefully adjusted to ensure that it is supported at night.

Terms and conditions

There is a gradation of bandage complexity. The choice of CC should be as simple as possible at the outset, even if it may become more complex if the desired results in terms of edema volume are not achieved.

The simplest modality, used as a first-line treatment, involves winding a cotton strip from distal to proximal. At least two overlays ensure sufficient rigidity. On harder areas of edema, overlays can be increased.

The way these bands are applied depends on the clinical aspect of the lymphedema. As these non-elastic bands exert only slight pressure, the number of superimpositions does not lead to a tourniquet effect, even if the number of layers is greater proximally.

A bi-elastic band is applied to this cotton strip.

A disto-proximal pressure gradient is maintained thanks to the difference in radius of curvature, which increases from distal to proximal. The number of layers is 3 or 4 or more, depending on the band’s resistance to stretching and the consistency of the lymphedema.

This easy-to-use bandage gives good clinical results.

Monitoring and precautions

Lymphedema treated with customized bandages needs to be checked at the start of its application, otherwise it may have undesirable or unexpected effects. Excessive compression or rigidity should be checked. Skin condition or sensitivity disorders must be taken into account, and demonstrate that no one-type technique can be applied.

Wearing a bandage should not cause pain. It may cause slight functional discomfort due to the accumulation of band thicknesses. Skin tolerance is monitored. For example, observe the first commissure of the hand, the insertion of the foreleg and the bony reliefs.

Plexopathies or diabetes do not contraindicate bandaging, but again require case-by-case adaptation. On the other hand, there is an absolute contraindication to lower limb compressions in cases of severe arteriopathy (systolic pressure index < 0.6).

In France, the use of pneumatic pressotherapy has been the subject of much controversy. However, the ISL document does indicate this. While it is recommended for maintenance treatment on the other side of the Atlantic, in Europe it is used on a daily basis in many lymphedema treatment units as an initial treatment. To specify its indications in lymphedema, we first need to define its mode of action, and determine how it should be used.

Pressotherapy can target three different areas: venous, lymphatic and interstitial.

• On the vein, pressurizing the limb from distal to proximal allows blood to be evacuated from the venous tree.
• On the lymphatic system, its adapted action enables the lymph present in the collector to move forward. This effect of improving lymphatic evacuation was suggested by work on anatomical parts, then by lymphoscintigraphy on patients with lymphedema. Its effect on protein resorption, assessed by lymphoscintigaphy, is assessed differently according to study protocols.
• In the interstitial environment, its action displaces the fluid in the sliding spaces, enabling resorption to take place in a different area from the lymphedema.

All these effects depend on factors such as the area where pressotherapy is applied, how long it is used and the level of pressure chosen.

Thanks to its effects, pressotherapy is at the heart of lymphedema treatment, especially in the case of irreversible lymphedema. It’s easy to use. This makes it a valuable tool, especially as it can be left in place for as long as required. However, the devices used must be designed for therapeutic purposes, with alveolar overlapping, programmable adaptability and pressure settings that can exceed 30-40 mm Hg.

Application area

One essential principle sums up the choice of the optimal pressotherapy program: the action should be focused on the site of lymphedema. No need to act underneath. No action above; except to move lymphedema away from the blockage zone. It’s worth noting that in most cases, this removal is not achieved by pressotherapy, but by manual lymphatic drainage localized in the area bordering the upper portion of the lymphedema and slightly beyond (± 20 cm).

In order to make the most rational choice, it is then sufficient to consider the spontaneous reversibility of lymphedema. If it completely disappears with a simple night decubitus position, we can start from the periphery (anterograde approach) and progress to the root of the limb if the lymphedema extends there, or go beyond its proximal location with a pneumatic chamber.

If it no longer or incompletely clears, a retrograde approach such as manual lymphatic drainage should be used. At least during the first few sessions. In fact, because of the rapid reduction in volume, any suspended compression can then produce dermal reflux of a greater or lesser portion of lymphedema. An anterograde approach will follow in subsequent sessions.

Pressure to be used

At a time when light pressure is still considered to have abusive powers, it would be a mistake to consider that only light pressure should be applied to all forms of lymphedema.

Any limitation to 30 mm Hg is indefensible today. This restriction is a thing of the past. Lymphedema is treated by applying appropriate pressure. Here again, action can be ordered according to the reversibility of lymphedema. As long as the pressure is reduced by decubitus, 30 mm Hg is sufficient.

Stronger compression is reserved for irreversible spontaneous lymphedema. It is then modulated according to its consistency.

One exception: any case presenting pain and/or an active wound (open, in the process of cica- trization, area at risk due to associated critical ischemia). In these cases, the pressure does not exceed 30 mm Hg; the approach is retrograde and begins one chamber above.

Application time per compressed segment

Another guiding principle is that the more “consistent” the lymphedema, the slower the pressure wave. However, the greater the force required to mobilize it, the smaller the compression surface. In addition, the sleeve or boot has to be made up of multiple compartments, allowing numerous possibilities for individualizing the program. The Eure duc TP07-i pressotherapy unit used at the Pôle Equilibre & Santé practice in Bascharage is a state-of-the-art medical device featuring 7 individual chambers stacked one on top of the other.

Lastly, abdominal chambers cannot be used, as they would create an obstacle to drainage rather than a “call”.

What’s more, if the valves – venous and/or lymphatic – are incontinent, they will produce blood and/or lymphatic reflux, which may also extend into the interstitial compartment (dermal reflux).

Order of use of pressotherapy in a decongestion session

Pressotherapy can be used before, during or after manual lymphatic drainage. Its use prior to manual lymphatic drainage is indicated for very “consistent” lymphedema: pressotherapy prepares what manual lymphatic drainage refines. Similarly, manual lymphatic drainage can also be performed after the removal of a bandage that may have left morphological irregularities.

Manual lymphatic drainage is performed simultaneously when the amount of lymphedema displaced by pressotherapy risks accumulating at its root or blocking drainage. It can precede pressotherapy: manual lymphatic drainage triggers drainage; pressotherapy prolongs its action.

In other cases, pressotherapy assists manual lymphatic drainage where there is a blockage or resistance. Finally, when the support orthosis (sleeve or stocking) has caused accumulation beyond its proximal limit, manual lymphatic drainage is still performed before pressotherapy.

Long-term use of pressotherapy

Long-term use of pressotherapy is, like daily use of the orthosis, a necessity in chronic forms of lymphedema. It does not engender any presso-addiction or presso-addiction: as with all the other means available, pressotherapy erases a consequence of lymphatic pathology, but the cause of lymphedema persists!

Finally, it has no adverse effects such as root congestion or reflux to the external genitalia.

Contraindications of pressotherapy

Contraindications include suspected or confirmed acute deep-vein thrombosis, erysipelas, lymphangitis, pressure-induced urticaria, systemic decompensation (cardiac, pulmonary, hepatic, renal). They are relative in the presence of severe ischemia and rubber contact urticaria. There are still some non-indications: fatty hypertrophies, primary prevention of lymphedema.