08/04/231

Intermittent Pneumatic Intermittent Pneumatic Compression TherapyCompression Therapy

NSW PAR - 13th March 2009 - Blue Mountains

Craig EvansPhysiotherapist

Rankin Park Limb Centre

Current Edema Management OptionsCurrent Edema Management Options RRDs

Silicone liners

Shrinkers

Bandaging

Prosthesis

Intermittent Pneumatic Compression Therapy (IPC)

What is IPC?What is IPC?

Variables:

Constant

Intermittent

Sequential – number of chambers

Duration , intensity (pressure) , Rx/rest phases

IPC Evidence - Settings

Author Type Duration (Mins) mmHg Inflation/Rx/Rest phasesNikolovska (2002) ISPC 60, 5/7, 6 months 40-50 180s inflation time, 30s Rx, 60s rest

Coleridge-Smith (1989) ISPC 240, daily    

Schuler (1996) ISPC 60am, 120pm 40-50 10s Rx, 60s rest (10mmHg)

McCulloch (1994) IPC 60, 2/7 50 90s Rx, 30s rest

Kumar (2002) IPC 60 x 2 daily, 4 months 60 90s inflation, 90s deflation

Rowland (2000) IPC ?S 60 x 2 daily, 2-3 months 50  

Nikolovska (2005) - fast ISPC 60, daily, 30-45 0.5s inflation, 6s Rx, 12s deflation Vs.

Nikolovska (2005) - slow ISPC 60, daily, 30-45 60s inflation, 30s Rx, 90s deflation

Ginsberg (1999) IPC ?S 20, twice daily 50 ?

Kakkos (2000) ISPC ? 45 11s inflation, ?s Rx, 60s deflation

Lymphedema framework (2006) ISPC 30-120 30-60 nil recommended

Delis (2000) IPC >240 total per day 180 3s inflation, 17s deflation

Delis (2001) ISPC ? 120 4s inflation, 16s deflation

Chleboun (1995) IPC 20, daily, 5 days 60 40s inflation, 20s deflation

Evidence for use of IPCEvidence for use of IPC Wienert et al (2005) – Indications:

– DVT prophylaxis

– Post-phlebitic syndrome

– Venous edema

– Foot / Ankle ulcers

– Lymphedema

– Lipodema

– Peripheral arterial disease

– Diabetic foot

– Hemipeglia

IPC Evidence - AmputeesIPC Evidence - Amputees1 unobtainable Article!!!

Experiences in the use of a pneumatic stump shrinker.

Author: REDFORD JB Journal: ICIB Issue: 12(10), 1-6, 14 Year: 1973 Description: Describes methods used to reduce stump edema occurring after amputation. Includes the Jobst intermittent compression unit which is applied to reduce edema prior to casting the amputation stump for a temporary or permanent socket. Rigid- plaster dressings have been used satisfactorily, as has Tensor bandage wrapping and lycra tubigrip stump socks. Reduction of edema allows the patient to be fitted with a permanent prosthesis in 40 to 60 days.

Inter-Clinic Information Bulletin (ICIB) was initiated in 1961 in the US to improve timely information sharing between prosthetic and orthotic clinics for children. Now known as Clinical Prosthetics and Orthotics

IPC Evidence - AmputeesIPC Evidence - AmputeesAnecdotally

Reduces edema

More effective on TTAs than TFAs

? Desensitization effect

Used in other centres / states for over 30 years

IPC Evidence - LymphedemaIPC Evidence - LymphedemaThe Lymphedema Framework (2006)

IPC recognised as an effective treatment

Multi-chambered IPC > single chambered

Other compressive therapy / garments to prevent rebound

IPC Evidence – DVT ProphylaxisIPC Evidence – DVT Prophylaxis Kakkos / Nicolaides / Griffin / Geroulakos /

Wolfe / ....collaboration

“... is as effective as heparin” (Nicolaides et al 1980)

Lacks hemorrhagic side effects of anticoagulants – better option in trauma, brain injury (Kakkos et al, 2005)

Potentially effective at preventing venous stasis and therefore DVT (Kakkos et al, 2000)

IPC Evidence – PVD / wound managementIPC Evidence – PVD / wound management

Nelson Mani and Vowden (2008) Cochrane Review – 7 RCTs on venous ulcers

IPC may increase healing compared with no compression.

not clear whether it increases healing when added to treatment with bandages

Rapid IPC is better than slow IPC in 1 trial

IPC Evidence – PVD / wound managementIPC Evidence – PVD / wound management

Ginsberg et al (1999)

– IPC reduces symptoms of severe post-phlebitis syndrome in ~ 80% clients who are unable to tolerate pressure stockings

Delis et al (2000)

– IPC enhances collateral circulation ... “an effective treatment in symptomatic PVD”

Delis et al (2001)

– Thigh IPC +/- calf IPC improves native arterial and infra-inguinal bypass graft flow.

IPC - Contra indicationsIPC - Contra indications Decompensating heart insufficiency (?CCF)

Extensive thrombophlebitis, thrombus or suspected thrombus

Neuropathy

Infectious disease (?infection)

Acute soft tissue trauma to the extremities

Occlusive lymphedema

(Wienert et al, 2005)

IPC - Contra indicationsIPC - Contra indications Cancer?

Increasing lymph and blood flow

Lachmann et al (1992)

– peroneal neuropathy and lower leg compartment syndrome following IPC for surgical DVT prophylaxis.

IPC - Potential complicationsIPC - Potential complications Peroneal nerve palsy/neurovascular

compression

Ischaemia

Compartment syndrome

PE

Genital lymphedema

(Wienert et al, 2005)

So what do we use?So what do we use? ISPC

Multi chambered unit

Preset cycles (28:11)

45-60 mmHg

Up to 30 mins

1 week to 2-3 months post op

Infection control procedures

Measuring improvement / volume Measuring improvement / volume reductionreduction Tape

Fit of prosthesis / RRD

Other:

CAD CAM digitizer / scanner

Serial Casting

Archimedes principle

Doppler / Duplex / ABPI (ankle brachial pressure index)/ tcPO2

Implications for Amputee ManagementImplications for Amputee Management

No empirical residual limb evidence

Physiological evidence – potential residual and intact limb benefit

Useful where other Rx strategies are not tolerated well.

Dosage rationale / evidence

– “rapid” IPC is better than “slow”

– determined by in built machine settings.

IPC + other compression modalities to prevent rebound edema

Anecdotally effective

There is plenty of scope for producing better quality amputee related evidence!

ReferencesReferences Ginsberg, Magier, Mackinnon and Gent (1999). “Intermittent compression units for severe post-phlebitic

syndrome: a randomised crossover study.” CMAJ, May, 160(9), 1303-1306.

Nelson EA, Mani R, Vowden K. Intermittent pneumatic compression for treating venous leg ulcers. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD001899. DOI: 10.1002/14651858.CD001899.pub2.

Gilbart, Oglivie-Harris, Broadhurst and Clarfield (1995). “Anterior tibial compartment pressures during intermittent sequential pneumatic compression therapy.” American Journal of Sports Medicine, 23(6): 769-772

Engstrom, B., Van de Ven, C.. (1999). “Therapy for Amputees” (3 rd Edition) Churchill Livingstone.

Kakkos, Griffin, Geroulakos and Nicolaides (2005). “The efficacy of a new portable sequential compression device (SCD Express) in preventing venous stasis.” Journal of Vascular Surgery, 42(2): 296-303.

Kakkos, Szendro, Griffin, Daskalopoulou and Nicolaides (2000). “The efficacy of the new SCD Response Compression System in the prevention of venous stasis.” Journal of Vascular Surgery, 32(5): 932-40.

Delis, Nicolaides, Wolfe and Stansby (2000). “ Improving walking ability and ankle brachial indicies in symptomatic peripheral vascular disease with intermittent pneumatic foot compression: a prospective controlled study with one-year follow-up.” Journal of Vascular Surgery, 31(4): 650-661.

Delis, Husmann, Cheshire and Nicolaides (2001). “Effects of intermittent pneumatic compression of the calf and thigh on arterial calf inflow: a study of normals, claudicants and grafted arteriopaths.” Surgery, 129(2): 188-95 Feb (abstract only)

Nicolaides, Fernandes, Fernandes and Pollock (1980). Intermittent sequential pneumatic compression of the legs in the prevention of venous stasis and postoperative deep venous thrombosis.” Surgery, 87(1): 69-76, Jan. (Abstract only)

Wienert, Partsch, Gallenkemper, Gerlach, Junger, Marschall and Rabe (2005). “Guideline: Intermittent pneumatic compression.” Phlebologie, 34(3): 176-80 (German) 

Lachmann, Rook, Tunkel and Nagler (1992). “Complications associated with intermittent pneumatic compression.” Archives of Physical Medicine and Rehabilitation, 75(5): 482-5. (Abstract only)

Lymphedema Framework (2006) . Best Practice for the Management of Lymphedema. International consensus. London: MEP Ltd.