Transcript Intermittent Pneumatic Compression Therapy (IPC) for

Intermittent Pneumatic
Compression Therapy
NSW PAR - 13th March 2009 - Blue Mountains
Craig Evans
Physiotherapist
Rankin Park Limb Centre
17/07/2015
1
Current Oedema Management Options
 RRDs
 Silicone liners
 Shrinkers
 Bandaging
 Prosthesis
 Intermittent Pneumatic Compression Therapy
(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 phases
Nikolovska (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
Lymphoedema 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 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
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 - Amputees
Anecdotally
 Reduces oedema
 More effective on TTAs than TFAs
 ? Desensitization effect
 Used in other centres / states for over 30 years
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
 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
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 management
Ginsberg et al (1999)
– IPC reduces symptoms of severe postphlebitis 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
 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 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
 Peroneal nerve palsy/neurovascular
compression
 Ischaemia
 Compartment syndrome
 PE
 Genital lymphoedema
(Wienert et al, 2005)
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
 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
 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

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)

Lymphoedema Framework (2006) . Best Practice for the Management of Lymphoedema. International
consensus. London: MEP Ltd.