Evaluation of the performance of a new compression system in patients with lymphoedema

A dual realist review: Compression for leg swelling at the end of life has potential quality of life benefit

AIMS

To examine the evidence for the use of compression in the general population and determine how far it can be used to inform treatment at the end of life.

DESIGN

In advanced illness, some patients suffer lower limb swelling and its resulting problems. In the general population, compression is used to treat lower limb swelling, but little is known about its use at the end of life. This review is designed to deeply explore the available evidence and identify what is known and areas for further research.

DATA SOURCES

Five databases were searched; CINAHL, MEDLINE, Embase, AMED and Cochrane, in November 2021. Reference lists for included studies were hand-searched. A web search was carried out.

REVIEW METHODS

Two parallel realist reviews were performed. The first reviewed the use of compression in the general population. The second explored lower limb swelling at the end of life. Findings were screened using inclusion and exclusion criteria, quality assessed and qualitative and quantitative data extracted.

RESULTS

The initial searches returned 1179 articles in review one and 839 articles in review two. Following the screening, 10 articles remained in each review for analysis. A programme theory was drawn for each review. The theories had sufficient similarities to allow evidence from the general population to be used to make recommendations for those at the end of life.

IMPACT

People with advanced illness and leg swelling suffer physically and psychologically. Compression delivers a reduction in swelling and quality of life benefit in the general population. This study found people with advanced illness may experience the same benefits. A cautious approach should be taken and stockings or adjustable Velcro compression devices (AVCDs) are likely to be the best starter interventions. Existing guidelines should also be consulted. Further research to develop the right intervention in this group is needed.

Pressure Curves, Static and Dynamic Stiffness of Different Two-Component Compression Systems for the Treatment of Chronic Edema of the Lower Limbs

Background: Compression is a cornerstone modality in edema treatment. Different types of bandages are available in clinical practice. Short-stretch bandages are commonly used; however, newer technologies such as the two-component compression system are available as well. This study assesses the pressure curves and static and dynamic stiffness (Static Stiffness Index [SSI] and Dynamic Stiffness Index [DSI]) of two different two-component compression systems, Coban and CoFlex, for edema treatment. Methods and Results: For this prospective cohort study, 12 healthy volunteers were recruited. The healthy volunteers wore both two-component compression systems for 48 hours. Pressure sensors (PicoPress^®; Microlab, Italy) were placed at 10 and 25 cm above the internal malleolus and 10 pressure readings were used to obtain pressure curves. The SSI and DSI were assessed. Additionally, comfort (ICC compression questionnaire) and adverse events were assessed as well. Both two-component compression systems exert a sufficient amount of sub-bandage pressure, although CoFlex exerts systematically significantly lower pressure in comparison with Coban. This difference in sub-bandage pressure remains constant over 48 hours. Both two-component compression systems are sufficiently stiff (stiffness >15 mmHg) and remain stiff over time. Conclusions: Both two-component compression systems have pressure curves that are high enough to motivate their use in the treatment of chronic edema. Additionally, both systems were found to be comfortable and have clinically effective SSI and DSI values.

The efficacy of different bandaging methods in patients with breast cancer-related lymphedema: A prospective, randomized study

Objectives

The aim of this study was to evaluate the comparative efficacy of 3MTM CobanTM 2 layer system and conventional multi-layer short-stretch bandaging in terms of volume reduction, ultrasonographic measurements, functional status, and quality of life (QoL) in the treatment of patients with breast cancer-related lymphedema (BCRL).

Patients and methods

This prospective, single-blind, randomized study included a total of 60 BCRL patients (60 females; mean age 54.9±9.6 years; range, 30 to 73 years). The patients were randomly allocated to Group 1 (n=30) and Group 2 (n=30). Both groups received complex decongestive therapy (CDT) including skin care, lymphedema exercises, and manual lymphatic drainage (MLD) combined with traditional multi-layer short-stretch bandaging five times per week for three weeks in Group 1 and with 3MTM CobanTM 2 layer system bandaging two times per week for three weeks in Group 2. Differences in volumes, excess volumes, ultrasonographic measurements, QoL, and functional assessment scores were evaluated at baseline, after three weeks of intensive treatment period, and at two months of follow-up. Functional status was evaluated by the Quick Disability of Arm Shoulder and Hand Questionnaire (Q-DASH), while the QoL was assessed using the Turkish version of Lymphedema Quality of Life Questionnaire-Arm (LYMQOL-Arm). The duration and easiness of applying bandages by physiotherapists and comfortableness of bandages according to patients and physiotherapists were also evaluated using a questionnaire.

Results

The demographic and clinical properties were similar between the groups. There were significant improvements in the volumes, excess volumes, ultrasonographic measures, functional scores, and QoL scores in both groups at the end of treatment. The improvements were sustained at two months of follow-up.

Conclusion

The 3MTM CobanTM 2 layer bandaging as a part of CDT twice a week for a period of three weeks can significantly reduce the volume and improve the disability and impaired QoL, similar to conventional short-stretch multi-layer bandages. In addition, treatment with this layer system enables a time-efficient, easy, and comfortable application of bandaging with increased mobility of the upper extremity.

Efficacy and efficiency of a new therapeutic approach based on activity-oriented proprioceptive antiedema therapy (TAPA) for edema reduction and improved occupational performance in the rehabilitation of breast cancer-related arm lymphedema in women: a controlled, randomized clinical trial

BACKGROUND

Breast cancer (BC) is a major public health issue. More than one out of five women treated for breast cancer will develop lymphedema in an upper extremity. Current evidence advocates transdisciplinary oncological rehabilitation. Therefore, research in this area is necessary since limited consensus having been reached with regard to the basic essential components of this rehabilitation. Consensus has, however, been reached on the use of decongestive lymphedema therapy (DLT), but due to a lack of tests, the necessary dosages are unknown and its level is moderately strong. This study attempts to verify both the efficacy of activity-oriented proprioceptive antiedema therapy (TAPA), as compared to conventional treatments such as DLT or Complex Physical Therapy (CPT), as well as its efficiency in terms of cost-effectiveness, for patients affected by breast cancer-related arm lymphedema.

METHODS

Controlled, randomized clinical trial with dual stratification, two parallel arms, longitudinal and single blind. 64 women with breast cancer-related arm lymphedema will take part in the study. The experimental group intervention will be the same for stage I and II, and will consist of neuro-dynamic exercises oriented to the activity, proprioceptive neuromuscular facilitation activities and proprioceptive anti-edema bandaging. The control group intervention, depending on the stage, will consist of preventive measures, skin care and exercise-prescribed training in the lymphedema workshop as well as compression garments (Stage I) or conservative Complex Decongestive Therapy treatment (skin care, multi-layer bandaging, manual lymphatic drainage and massage therapy) (Stage II).

RESULTS

Sociodemographic and clinical variables will be collected for the measurement of edema volume and ADL performance. Statistical analysis will be performed on intent to treat.

DISCUSSION

It has been recommended that patient training be added to DLT, as well as a re-designing of patient lifestyles and the promotion of health-related aspects. In addition, clinical trials should be undertaken to assess neural mobilization techniques and proprioceptive neuromuscular facilitation should be included in the therapy. Cohesive bandaging will also be performed as an early form of pressotherapy. The proposed study combines all of these aspects in order to increased comfort and promote the participation of individuals with lymphedema in everyday situations.

LIMITATIONS

The authors have proposed the assessment of the experimental treatment for stages I and II. One possible limitation is the lack of awareness of whether or not this treatment would be effective for other stages as well as the concern for proper hand cleansing during use of bandages, given the current COVID-19 pandemic situation.

TRIAL REGISTRATION

This trial was registered in ClinicalTrials.gov ( NCT03762044 ). Date of registration: 23 November 2018. Prospectively Registered.

Compression therapy in lymphedema: Between past and recent scientific data

Aim

To extrapolate and discuss the scientific data on compression in lymphedema treatment, so to review old and innovative concepts about pressure, stiffness and other interplaying factors related to its efficacy and comfort.

Material and methods

Narrative review based on search in Medline/Google Scholar through key-words related to compression in lymphedema.

Results

Currently available literature lacks relevant details about data on protocol, devices, techniques, interface pressure, stiffness, as well as biases are represented by the different descriptions to present the outcomes. More recent evidence from adjustable wrap devices and elastic garments question the need for high pressure (especially for the upper limb) and stiffness in lymphedema treatment.

Conclusions

At present time a very strong compression pressure exerted by material with high stiffness seem to be questionable in lymphedema treatment. A low pressure provides the best outcomes in arm lymphedema, while a pressure in the range of 40–60 mm Hg seems to provide higher efficacy in lower limb lymphedema, provided it is maintained overtime. A high stiffness seems to be unnecessary to treat chronic edema. Future clinical trials, including proper description of treatment methodology and adequate investigating instrumental tools, are awaited to possibly corroborate the conclusive outcomes of our review.

Lymphedema diagnosis, treatment, and follow-up from the view point of physical medicine and rehabilitation specialists

Lymphedema is an incurable, debilitating and progressive condition, leading to physical and psychosocial consequences for the patients, if left untreated. The Physical Medicine and Rehabilitation (PMR) specialist is responsible for the differential diagnosis and evaluation of the patient to tailor management and rehabilitation strategies. Therefore, the PMR specialist must have knowledge and education on the diagnosis of disease and possible complications as well as evaluation, treatment and follow-up of the patient. In this review, the pathophysiology, epidemiology, and diagnostic and therapeutic approaches of lymphedema as well as preventive strategies and follow-up strategies are discussed in the light of the current literature.

Comparison of the effectiveness of complex decongestive therapy and compression bandaging as a method of treatment of lymphedema in the elderly

Background

Lymphedema is a chronic condition which significantly lowers the quality of patient life, particularly among elderly populations, whose mobility and physical function are often reduced.

Objectives

The aim of the study was to compare the effectiveness of multi-layer compression bandaging (MCB) and complex decongestive therapy (CDT), and to show that MCB is a cheaper, more accessible and less labor intensive method of treating lymphedema in elderly patients.

Patients and methods

The study included 103 patients (85 women and 18 men) aged ≥60 years, with unilateral lower limb lymphedema. The subjects were divided into two groups: 50 treated with CDT and 53 with MCB. Pre- and post-treatment BMI, and average and maximum circumference of the edematous extremities were analyzed.

Results

Reduction in swelling in both groups was achieved after 15 interventions. Both therapies demonstrated similar efficacy in reducing limb volume and circumference, but MCB showed greater efficacy in reducing the maximum circumference.

Conclusion

Compression bandaging is a vital component of CDT. Maximum lymphedema reduction during therapy and maintaining its effect cannot be achieved without it. It also demonstrates its effectiveness as an independent method, which can reduce therapy cost and accessibility.

Compression therapy in obese patients

Triggered by obesity, venous (obesity-associated dependency syndrome) and lymphatic drainage disorders (obesity-associated lymphoedema) can develop, which in themselves require compression therapy, or other comorbidities with indication for compression therapy may exist. In obese patients, some specific features have to be observed in compression therapy:

- An adequate initial decongestive phase with padding and bandage materials,

- Compression hosiery with a high degree of stiffness (high-strength materials, where appropriate, flat-knitted) and optimal fit (meticulous fitting),

- Garment types that are suitable for daily use, if necessary, multi-part garment,

- Need for aids or auxiliary persons to ensure correct use,

- Concomitant consistent, intensive, lipid-replenishing skin care and optimised hygiene to reduce complications and side effects

- Regular medical check-ups to ensure correct fit of the leg compression garment.

Sometimes, particularly at the initial provision and in patients with a complicated physical shape, the stockings have to be modified several times before an optimal fit is achieved.

Case study: Obesity, genital oedema and lower limb compression bandaging

The purpose of this article is to present an evidence-based rationale for lymphoedema compression bandaging, one aspect of treatment for a patient with complex lower limb lymphoedema. The current health care climate requires treatment decisions to be transparent, based on the best available evidence. The challenge faced by community nurses is to formulate treatment plans which incorporate patients' preferences and best use limited resources provided by clinical environments. The article appraises research in order to formulate a suitable treatment plan and provides discussion and reflection regarding the challenges faced by the nursing profession in achieving evidence-based practice. Evidence-based practice is beneficial in formulating patient-centred and cost-effective treatment plans. Developing competence is not straightforward; however, clinical guidelines can provide much needed guidance.

Clinical audit of a lymphoedema bandaging system: a foam roll and cohesive short stretch bandages

OBJECTIVE

Late-stage lymphoedema is characterised by chronic swelling, shape distortion, inflammatory processes and tissue fibrosis. Our aim was to perform a clinical audit of a lymphoedema compression bandaging system (Rosidal Soft foam roll layer and figure-of-eight application of Actico cohesive inelastic bandages) specifically designed for patients with late stage lower limb lymphoedema.

METHOD

The audit explored suitability of the bandaging system, benchmarking limb volume changes with research evidence, and reporting patient and practitioner evaluations.

RESULTS

A mean reduction (33%) in excess limb volume was reported for the 11 patients with unilateral lymphoedema who completed a course of bandaging over 12 days. Mean percentage reduction of absolute limb volume after treatment was 8%. Patient and practitioner evaluations indicated the suitability of this bandage system for patients with late stage lymphoedema in terms of comfort and effectiveness.

CONCLUSION

The bandaging system is suitable for patients with late stage chronic swelling. Two parameters for calculating change in limb volume are not interchangeable. Future evaluation of the bandaging system, using validated outcome measures within a comprehensive research study is required.

DECLARATION OF INTEREST

Activa Healthcare provided financial support to the project and supplied the materials.