Taping 1
Study Notes on Physiotherapy Treatment Principles
Learning Outcomes
Understanding the Principles:
Principles of pressure therapy, bandages, slings, and tape as essential components of physiotherapy treatment, aiming to restore function, manage pain, and prevent further injury.
Clinical Indications:
Identifying specific clinical indications for the appropriate use of pressure therapy interventions, understanding the conditions that benefit most from these applications.
Recognizing absolute contraindications and necessary precautions to ensure patient safety and optimize treatment efficacy, preventing adverse outcomes.
Evidence Summation:
Summarizing the current evidence base and best practices related to these physiotherapy techniques, supporting clinical decision-making with robust research findings.
Pressure Therapy
Definition:
Pressure therapy is a therapeutic intervention designed to facilitate the emptying of the superficial and deep lymphatic or venous systems. It aims to reduce edema and improve circulation while carefully avoiding increased load on the heart or damage to delicate vascular tissues.
Treatment Goals:
Primarily used in cases of insufficient venous return or lymphatic drainage, addressing chronic conditions and preventing acute complications, such as:
Lymphoedema: Chronic swelling caused by a dysfunctional lymphatic system, where external pressure aids in moving lymphatic fluid.
Venous ulcers: Non-healing wounds on the legs due to chronic venous insufficiency, where compression improves circulation and reduces edema, promoting healing.
Prevention of blood clots (Deep Vein Thrombosis - DVT): Applied post-surgery or during prolonged immobility to mechanically assist venous return and reduce venous stasis.
Benefits:
Improves venous pump function: External pressure aids the muscular contraction of the calf pump, enhancing blood return to the heart.
Reduces capillary filtration: By increasing interstitial tissue pressure, compression counteracts the hydrostatic pressure in capillaries, thereby reducing the leakage of fluid into the interstitial space.
Facilitates lymphatic drainage: The external pressure helps to push lymphatic fluid through the congested lymphatic vessels, reducing swelling.
Supporting Evidence:
Rooney et al. (2018) provide foundational support for the physiological mechanisms and clinical applications of pressure therapy, emphasizing its role in managing chronic edema.
Mechanism of Action
Venous Pump Mechanism:
The venous system relies on a sophisticated pump mechanism, primarily involving the calf muscles and venous valves. When contracted skeletal muscles are engaged, they compress deep veins, pushing blood upwards. The valve then opens.
During muscle relaxation, the valve closes to prevent the gravitational backflow of blood, ensuring unidirectional flow towards the heart. External compression can augment this natural mechanism.
Effects on Capillary Filtration:
Compression increases structural stiffness of the tissues surrounding capillaries, which in turn increases interstitial pressure. This elevated interstitial pressure counteracts the hydrostatic pressure within the capillaries, thereby reducing the net outward filtration of fluid from the capillaries into the interstitial tissue, as elucidated by Mortimer & Levick (2004).
Treatment Parameters
Types of Pressure:
Pressure can be administered as either intermittent pneumatic compression (IPC) or continuous compression (e.g., via bandages or garments).
Application in Compression:
Intermittent compression specifically favors venous drainage through the application of periodic and precisely graded pressure. This dynamic pressure facilitates the propulsion of fluid from more peripheral areas (e.g., ankles) towards the central circulatory system (the heart).
Dosage Standards:
The appropriate pressure level is critical and is measured in millimeters of mercury (mm Hg):
= Low pressure: Often used for DVT prevention, mild oedema, or maintenance therapy.
= Moderate pressure: Commonly used for moderate oedema, venous stasis ulcers, and active lymphoedema management.
= High pressure: Reserved for severe oedema, chronic venous insufficiency, or resistant lymphoedema.
Note: Cuff pressures can exceed 80% of target pressure during inflation cycles for devices, but sustained pressure on the tissue should remain within therapeutic ranges.
Research Evidence
Upper Pressure Limit:
Evidence indicates that applying pressures higher than to the lower limb does not significantly enhance venous peak flow, suggesting a diminishing return beyond this threshold (Nicolaides et al., 1980).
Compression Efficacy:
Adding intermittent pressure therapy (IPT) to standard compression bandages may improve the healing rates of venous ulcers compared to compression bandages alone (Nelson et al., 2014).
While compression generally shows better outcomes than non-compression in the management of skin ulcers, intermittent pressure therapy has not been consistently proven superior to constant compression for ulcer healing (Nelson et al., 2014).
Compression Garments
Application in Conditions:
Widely used in chronic conditions such as breast cancer-related lymphoedema (BCRL). Findings from King et al. (2012) suggest that although intensive bandaging may result in greater initial volume reduction, patients often report poorer upper extremity functional status compared to those using compression garments due to bulkiness and reduced mobility.
Light compression corsets have been proven effective in providing abdominal support and reducing pain in conditions like low back pain or post-surgical recovery, as highlighted by Hansdorfer-Korzon et al. (2016).
Bandages
Types of Bandages:
Bandages are foundational tools for compression and support. Common materials used include:
Gauze: Lightweight, breathable, often used for wound dressings, light support, or to contain other materials.
Cotton: Absorbent, provides padding and protection, often used as an underlayer in multi-layer compression systems.
Elastic: Contains elastic fibers (e.g., latex or synthetic) allowing for stretch and controlled compression, key for therapeutic pressure application.
Classification by Properties:
Type 1: Conforming or retention bandages – designed primarily to hold dressings in place without applying significant compression.
Type 2: Light support bandages – provide mild compression and support, often used for sprains or strains to reduce swelling and provide comfort.
Type 3: Compression bandages – specifically designed to apply therapeutic levels of sustained pressure, crucial for managing edema and supporting circulation.
Treatment Goals of Bandaging
Objectives:
Reduction in swelling: Achieved through the application of positive external pressure, which helps to minimize the accumulation of blood, tissue fluid, and vascular cellular exudates in the interstitial space.
Reduction in pain: Provided via immobilization of an injured area, reducing movement at the site, or by offering mechanical support to strained or unstable structures, thus lessening proprioceptive input and muscle spasm.
Bandage Application Techniques
Application Steps:
Orientation: Hold the bandage so the roll is on top and closest to the body part being bandaged. This ensures a smooth, even application and allows for better control of tension.
Positioning: Wrap the body part in a maximal muscle contraction position, or a functional position. This technique ensures that fluid movement and circulation are optimized, as the muscles will relax into the bandage allowing for consistent pressure.
Wrapping Methods: Utilize specific techniques suited to the body part:
Spiral technique for uniform limbs such as the forearm or lower leg, overlapping turns evenly.
Figure-8 technique for joints like the knee or elbow, which allows for flexibility while maintaining support and compression.
Overlap: Overlap bandages by at least half of their width during application to ensure even pressure distribution and prevent gaps that could lead to uneven compression.
Circulation Check: Immediately after application, confirm adequate circulation beneath the bandage by checking capillary refill, skin color, temperature, and asking about sensation (e.g., tingling or numbness) to prevent neurovascular compromise.
Sling-Bandage Applications
Definition:
A combination of triangular bandages and cravats (folded triangular bandages) specifically used to immobilize and provide support to injured or healing structures, most commonly in the upper limb.
Types of Slings:
Cervical slings: Used for simple arm support where only elevation is needed, often secured around the neck.
Shoulder-arm slings and swathe: Designed for more serious injuries like shoulder dislocations or humeral fractures, immobilizing the shoulder girdle and humerus by binding the arm to the torso.
Collar and cuff slings: Provide support for the forearm, wrist, and hand when shoulder and elbow movement is not restricted but the hand needs elevation.
Application Principles:
Patient Stillness: Ensure the patient remains as still as possible during the application process to avoid further injury and facilitate proper positioning.
Correct Fit: The sling must be maintained at the correct fit and elevation to effectively support the injured part and prevent dependent edema or increased pain.
Immobilization Scope: For effective immobilization, it is crucial to immobilize not only the injury site but also the joints directly proximal and distal to it, creating a stable unit. For example, a forearm fracture would require immobilization of both the elbow and wrist joints.
Safety Precaution: Absolutely avoid tying slings behind the patient's neck, as this can cause direct pressure on the cervical vertebrae, leading to discomfort, nerve compression, or injury. Instead, knots should be positioned to the side of the neck or shoulder.