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Intermittent Pneumatic Compression Therapy. NSW PAR - 13 th March 2009 - Blue Mountains Craig Evans Physiotherapist Rankin Park Limb Centre. Current Oedema Management Options. RRDs Silicone liners Shrinkers Bandaging Prosthesis Intermittent Pneumatic Compression Therapy (IPC).

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intermittent pneumatic compression therapy

Intermittent Pneumatic Compression Therapy

NSW PAR - 13th March 2009 - Blue Mountains

Craig Evans

Physiotherapist

Rankin Park Limb Centre

current oedema management options
Current Oedema 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

evidence for use of ipc
Evidence for use of IPC
  • Wienert et al (2005) – Indications:
    • DVT prophylaxis
    • Post-phlebitic syndrome
    • Venous oedema
    • Foot / Ankle ulcers
    • Lymphoedema
    • Lipoedema
    • Peripheral arterial disease
    • Diabetic foot
    • Hemipeglia
ipc evidence amputees
IPC Evidence - Amputees

1 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 oedema occurring after amputation. Includes the Jobst intermittent compression unit which is applied to reduce oedema 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 oedema 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 amputees8
IPC Evidence - Amputees

Anecdotally

Reduces oedema

More effective on TTAs than TFAs

? Desensitization effect

Used in other centres / states for over 30 years

ipc evidence lymphoedema
IPC Evidence - Lymphoedema

The Lymphoedema Framework (2006)

IPC recognised as an effective treatment

Multi-chambered IPC > single chambered

Other compressive therapy / garments to prevent rebound

ipc evidence dvt prophylaxis
IPC 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 management
IPC 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 management12
IPC 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 indications
IPC - Contra indications

Decompensating heart insufficiency (?CCF)

Extensive thrombophlebitis, thrombus or suspected thrombus

Neuropathy

Infectious disease (?infection)

Acute soft tissue trauma to the extremities

Occlusive lymphoedema

(Wienert et al, 2005)

ipc contra indications14
IPC - 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 complications
IPC - Potential complications

Peroneal nerve palsy/neurovascular compression

Ischaemia

Compartment syndrome

PE

Genital lymphoedema

(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 reduction
Measuring improvement / volume reduction

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 management
Implications 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 oedema
  • Anecdotally effective
  • There is plenty of scope for producing better quality amputee related evidence!
references
References

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” (3rd 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)

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