Intermittent Compression By Jason, Brad, Tim, Yasuko Objectives • • • • • Purpose of Intermittent Compression Proper application When to use intermittent compression Discussion of Effectiveness Factors affecting usage of intermittent compression Instructions • Click on hyperlink to view slides of each topic or concept • Use hyperlink at bottom of page to return to topics page • Voice over Topics • • • • • • History Biophysical Characteristics Method of Application Examination of Evidence Based Research Review Questions References History • Add Voice Over • Various forms of intermittent compression have had a history of 70 years of clinical effectiveness. • Earliest appeared in 1930’s Topic page Biophysical Characteristics 1. Effects on Lymphatic and venous system – Mechanical pressure encourages blood to return to the heart through the venous system – Spreads edema proximally over a larger area to allow more lymphatic ducts to absorb the solid matter within the edema 2. Topic page Biophysical Characteristics cont. 1. Effect of intermittent compression a. Tissue • • • • • The gradient between tissue hydrostatic pressure and the capillary filtration pressure is reduced Second pressure gradient is formed between distal portion of extremity and the proximal portion of the extremity forcing fluids to move to the proximal portion Tissue thickness and muscle mass increases Fat mass decreases but not significantly enough for any clinical importance Bone mineral density- no significant effect Biophysical Characteristics cont. Range of motion • Increased from compression Pain • Video Method of Application 1. 2. 3. 4. 5. Indication Contraindication Precautions Recommendations for use Proper demonstration of physical agent 1. 2. Video Video Topic page Method of Application Indications – Post-traumatic edema— – Post-surgical edema— – Primary and Secondary lymphedema— Primary is caused by a congenital disorder of the lymphatic vessels. Secondary is caused by some other disease or dysfunction. Method of Application Indications – Venous Stasis Ulcers— Areas in the body in which tissue breakdown and necrosis occur as a result of impaired venous circulation. – Prevention of Deep Vein Thrombosis (DVT)— DVT is a blood clot that occurs due to poor circulation. Blood flow is slow enough to allow coagulation, causing a thrombus. Intermittent compression increases the circulation rate thereby preventing a clot from forming. Method of Application Contraindications – Heart failure or pulmonary edema— Increased pressure from the compression device damages the vasculature of the cardiovascular system decreasing the cardiac output. – Recent or acute DVT, thrombophlebitis, pulmonary embolism— The thrombus may become dislodged or the embolus may travel due to compression at the site of the clot. This would cause damage to the site where it becomes lodged after traveling through the bloodstream. Method of Application Contraindications • Obstructed lymphatic or venous return— Total obstruction of lymphatic or venous system may be caused by thrombus, damaged lymph nodes, tumor or other masses. The obstruction must be removed before compression can be applied. • Severe peripheral arterial disease or ulcers due to arterial insufficiency— Compression further closes down the diseased arteries causing lack of circulation. Method of Application Contraindications • Acute local skin infection— Device promotes environment conducive to infection, by increasing moisture and temperature. • Unhealed fractures and unresolved joint dislocations— compression device adds unwanted stress to the area. Method of Application Precautions • Impaired sensation or mentation— Patient is unable to recognize or feel pain or pressure. • Uncontrolled hypertension— Compression may further elevate a persons blood pressure. • Stroke or significant cerebrovascular insufficiency— Compression causes hemodynamic changes and alters circulation to the brain. Method of Application Precautions • Superficial peripheral nerves— Nerve compression is possible when too much pressure is applied. • Ischemia— compression elevates intramuscular pressure causing ischemia, similar to compartment syndrome. • Wrinkling of stockinette— Wrinkles cause high pressure areas and subsequent bruising. Method of Application Demonstration of Physical Agent Set up • • • • • • • Establish the absence of contraindications. Remove any jewelry Determine blood pressure Measure and record girth measurement Cover area with stockinette, smooth out wrinkles Select appropriate size of appliance for extremity Insert the injured limb into the appliance, avoid bunching of garments • Elevate the limb during treatment • Connect appliance to the compression unit Method of Application Initiation of Treatment • • • • • • Select temperature Select maximal pressure for associated extremity Select on/off times Select appropriate treatment time Informed consent Encourage gentle ROM exercises at distal phalanges • For longer treatments, interrupt occasionally to inspect capillary refill or unusual markings Method of Application Termination of Treatment • Select drain mode to remove air or fluid • Gently remove body part from appliance • Re-measure circumference to determine amount of edema lost • Apply compression wrap and any appropriate supportive device. Encourage elevation. Properties of Intermittent Compression Systems • • • • • Garment Pumps Timing Pressure Compression type Properties of Intermittent Compression Systems • Garment – Essential functions that the compression garment must provide include: covering a limb, remaining in place, and applying pressure. – All cuffs of today include an air bladder. – Need to be made of certain material that is designed for the specific use of the patient. • Deep Vein Thrombosis cuffs are designed for single use patients – Non-durable fabrics • Long term cuffs designed to be more durable and comfortable. Properties of Intermittent Compression Systems • Pumps – All current pumps are electrically driven with a few battery operated. This trend is due to simplification. Hand Pump Electrical Pump Properties of Intermittent Compression Systems • Timing – Generally, intermittent compression for DVT and arterial disease will have a shorter compression time than deflated time between compressions. – Adequate venous refilling must take place, therefore most devices have a decompression time of 40 seconds or greater. – 3:1 Duty cycle Properties of Intermittent Compression Systems • Pressure – The pressure applied during intermittent compression is always a compromise between efficacy and patient comfort. – Generally average of 40 mm Hg – Pressure changes depending on body part, lower extremity usually requires higher pressure than upper extremity. Properties of Intermittent Compression Systems • Compression type – Circumferential • Applies equal amount with pressure to all parts of extremity simultaneously. – Sequential • Device contains multiple bladders that allows for a single pressure to be applied to parts of the limb in sequence from distal to proximal. Examination of Evidence Based Research Cambier et al, (2003) found that the use of intermittent pneumatic compression in the rehabilitation of stroke patients may be of clinical importance for the restoration of sensory function. Morris et al, (2006) Although the data confirms that both types of intermittent compression suppress procoagulant activation, and that the rate of inflation produced no extra benefit in increasing global fibrinolysis, and my be less hemologically effective. Tsang et al, (2003) found that elevation or elevation with intermittent compression did not effectively decrease ankle volume for a proloonged period of time in patients with postacute ankle sprains. The therapeutic effects lasted less than 5 minutes after the limb was returned to a gravity dependent position. Topic page Review Questions Topic page References • • • • • • Morris, R. J. (2008). Intermittent pneumatic compression-system and applications. Journal of Medical Engineering & Technolog , 179-188. P.Albertazzi, S. S. (2005). Effect of intermittent compression therapy on bone mineral density in women with low bone mass. Bone , 662-668. Starkey, C. (2004). Therapeutic Modalities. Philadelphia: F.A. DAVIS COMPANY. Tsang, Kavin K.W., Hertel, Jay, Denegart, Craig R. (2003). Volume Decreases After Elevation and intermittent Compression of Postacute Ankle Sprains Are Negated by Gravity-Dependent Positioning. Journal of Athletic Training, 38, (4), 320-324. Prentice, W.E. (2008). Therapuetic Modalities in Sports Medicine (6th ed.). St. Louis, MO: Mosby-Year Book. Cameron, M.H. (2003). Physical Agents in Rehabilitation: From Research to Practice (2nd ed.). St. Louis, MO: Saunders.