Use of an inelastic bandage as an adaptation of the lymphatic drainage technique in lower limbs

Abstract

The inelastic bandage is an adaptation of the manual lymphatic drainage, which substitutes the circular movements of the fingers. A patient with lymphoedema underwent 20 sessions using the modified lymphatic drainage technique. Perimetric measurements were taken before and after each session, and volumetric measurements at the first, 10th, and 20th sessions. Limb circumference was significantly reduced at three points on the perimeter (10, 15 and 25 cm): 2.5 cm (7.3%), 2.5 cm (6.5%) and 1.5 cm (5%), respectively. Volumetry decrease of 26.4% from initial limb volume was observed. The use of the inelastic bandage proved to be an effective adaptation when compared with the results using other techniques described.

BACKGROUND

Manual lymphatic drainage (MLD) is part of the complex decongestive therapy used in the treatment of lymphodema.¹ Despite its proven effectiveness in draining lymphoedemas, MLD has some limitations, related mainly to the treatment of large lymphoedemas, in which the circular movements of the fingers is difficult to use for drainage. In modified lymphatic drainage (LD_modif) the circular movements of the fingers are substituted by the inelastic bandage. The aim of this case report is to describe the use of LD_modif, substituting the circular movements of the fingers with an inelastic bandage, in draining an infectious secondary lymphoedema.

CASE PRESENTATION

A 53-year-old woman with a 6 year history of stage III secondary lymphoedema of the right lower limb was referred for physical therapy treatment after resolution of her infectious erysipelas.

TREATMENT

Twenty treatment sessions were carried out using the LD_modif technique with a frequency of three sessions a week. LD_modif was applied using the inelastic bandage technique (fig 1). The inelastic bandage substituted for the circular movements of the fingers. The physical therapist wraps the polyester anelastic bandage around the limb to be treated, applying moderate pressure. The LD_modif follows the same procedures described by Leduc, substituting the circular movements of the fingers with the inelastic bandage.²

Figure 1.

Applying the inelastic bandage technique.

OUTCOME AND FOLLOW-UP

Perimetric and volumetric measurements of the patient’s lower limbs were assessed using techniques widely described in the literature.^2,3 Perimetric measurements were taken with a common measuring tape, and each limb was measured at 5 cm intervals, at 9 points below the popliteal reference line. The volumetry of the lower limbs was assessed in a conical shaped container with lower and upper diameters of 33 and 42 cm, respectively, a height of 65 cm, and a capacity of 58 litres. A small draining tube was placed 55 cm from the base and a receptacle with 100 ml gradations was used to collect the displaced water.² Perimetric measurements were taken before and after each session and volumetry was performed after the first, 10th, and 20th sessions.

The perimetric results showed an important and significant reduction in lower limb lymphoedema. The mean decrease in limb circumference was 1.8 cm. According to the perimetric results, the points 10, 15 and 25 cm from the reference line showed a significant decrease. The reduced percentage of the initial perimetric values assessed from the first to the 20th session at these points were 2.5 cm (7.3%), 2.5 cm (6.5%) and 1.5 cm (5%), respectively. With respect to volumetry, there was water displacement of 1400 ml from the first to 10th session, and of 1800 ml between the first and 20th sessions. A reduction of 26.4% in limb volume was observed. The perimetric and volumetric results are shown in table 1.

Table 1.

Perimetric and volumetric results

Points	Perimetry					Volumetry
	Perimetric values (cm)		Perimetry arithmetic means (SD) (cm)
	Initial	Final	Initial	Final	p Value	Session	Vd (ml)	% dif
10 cm	41.0	38.5	39 (0.73)	38 (0.61)	0.004	1st–10th	6800–5200	23.53
15 cm	38.5	36.0	37 (0.62)	36 (0.49)	0.010	10th–20th	5200–5000	3.8
25 cm	30.5	29.0	29.5 (0.4)	29 (0.48)	0.0004	1st–20th	6800–5000	26.47

10 cm, 15 cm, 25 cm = perimetry points; Vd = volume of water displaced in ml; % dif = percentage difference of displaced volume.

Perimetric measures were assessed by Student’s t test. Significance p⩽0.05 was used, with a bilateral approach.

Volumetry was analysed by means and percentage.

DISCUSSION

Holtgrefe et al,⁴ in a clinical case, showed a similar reduction to that of our study (between 9–10%), but they used several combined techniques such as manual lymphatic drainage, myolymphokinetic exercises, intermittent pneumatic compression, elastic support hosiery, and at home exercises, whereas our study used only the LD_modif technique. Compared with their results, the LD_modif technique appears to produce a greater reduction in lymphoedema.

Godoy et al⁵ found a moderate reduction of lymphoedema with a technique using rollers, but with a much larger number of sessions than in our study. They performed four or five sessions a week until a reasonable reduction in the lymphoedema was observed. After this period the patients continued the treatment for two or three sessions a week for 30 months. This study had a lower percentage reduction than that obtained by us, with a longer treatment time.

The MLD technique requires that both hands be placed around the whole circumference of the limb in order for the circular movements of the fingers to be effective. When lymphoedemas are very large, the hands and the circular movement cannot be placed around the whole circumference of the limb, and so the MLD drainage cannot be as efficient in achieving its main objective—the drainage of liquid from the limbs. The inelastic compression distributes pressure equally around the whole circumference of the limbs, improving drainage in large lymphoedemas.

This study shows a modified manual lymphatic drainage technique, which sought a more efficient practical approach, aimed at obtaining the same or perhaps even better results in cases of large lymphoedemas. The use of the inelastic bandage, in addition to following all the technical procedures of traditional manual lymphatic drainage, has the advantage of distributing pressure uniformly along the entire limb perimeter and is easily applied in patients with stage III lymphoedema.

LEARNING POINTS

• Drainage of large lymphoedema is very difficult.

• Inelastic bandage has the advantage of distributing pressure equally in the entire limb.

• Modified manual lymphatic drainage technique has been shown be efficient in lower limb lymphoedema volume reduction.