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Intermittent Pneumatic Compression Therapy

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

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  1. Intermittent Pneumatic Compression Therapy NSW PAR - 13th March 2009 - Blue Mountains Craig Evans Physiotherapist Rankin Park Limb Centre

  2. Current Oedema Management Options RRDs Silicone liners Shrinkers Bandaging Prosthesis Intermittent Pneumatic Compression Therapy (IPC)

  3. What is IPC? Variables: Constant Intermittent Sequential – number of chambers Duration , intensity (pressure) , Rx/rest phases

  4. IPC Evidence - Settings

  5. 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

  6. 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

  7. IPC Evidence - Amputees Anecdotally Reduces oedema More effective on TTAs than TFAs ? Desensitization effect Used in other centres / states for over 30 years

  8. 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

  9. 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)

  10. 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

  11. 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.

  12. 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)

  13. 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.

  14. IPC - Potential complications Peroneal nerve palsy/neurovascular compression Ischaemia Compartment syndrome PE Genital lymphoedema (Wienert et al, 2005)

  15. 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

  16. 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

  17. 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!

  18. 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.

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