Intermittent Pneumatic Compression Therapy NSW PAR — 13

Intermittent Pneumatic Compression Therapy NSW PAR - 13 th March 2009 - Blue Mountains Craig Evans Physiotherapist Rankin Park Limb Centre 17/03/2018 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) mm. Hg Inflation/Rx/Rest phases Nikolovska (2002) ISPC 60, 5/7, 6 months 40 -50 180 s inflation time, 30 s Rx, 60 s rest Coleridge-Smith (1989) ISPC 240, daily Schuler (1996) ISPC 60 am, 120 pm 40 -50 10 s Rx, 60 s rest (10 mm. Hg) Mc. Culloch (1994) IPC 60, 2/7 50 90 s Rx, 30 s rest Kumar (2002) IPC 60 x 2 daily, 4 months 60 90 s inflation, 90 s deflation Rowland (2000) IPC ? S 60 x 2 daily, 2 -3 months 50 Nikolovska (2005) - fast ISPC 60, daily, 30 -45 0. 5 s inflation, 6 s Rx, 12 s deflation Vs. Nikolovska (2005) - slow ISPC 60, daily, 30 -45 60 s inflation, 30 s Rx, 90 s deflation Ginsberg (1999) IPC ? S 20, twice daily 50 ? Kakkos (2000) ISPC ? 45 11 s inflation, ? s Rx, 60 s deflation Lymphoedema framework (2006) ISPC 30 -120 30 -60 nil recommended Delis (2000) IPC >240 total per day 180 3 s inflation, 17 s deflation Delis (2001) ISPC ? 120 4 s inflation, 16 s deflation Chleboun (1995) IPC 20, daily, 5 days 60 40 s inflation, 20 s 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 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 § 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 mm. Hg § 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)/ tc. PO 2

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. : CD 001899. DOI: 10. 1002/14651858. CD 001899. pub 2. § 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 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.