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15/01/2015 1 Intermittent Pneumatic Compression Therapy NSW PAR - 13 th March 2009 - Blue Mountains Craig Evans Physiotherapist Rankin Park Limb Centre.

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Presentation on theme: "15/01/2015 1 Intermittent Pneumatic Compression Therapy NSW PAR - 13 th March 2009 - Blue Mountains Craig Evans Physiotherapist Rankin Park Limb Centre."— Presentation transcript:

1 15/01/2015 1 Intermittent Pneumatic Compression Therapy NSW PAR - 13 th 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)


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

5 IPC Evidence - Settings AuthorTypeDuration (Mins)mmHgInflation/Rx/Rest phases Nikolovska (2002)ISPC60, 5/7, 6 months40-50180s inflation time, 30s Rx, 60s rest Coleridge-Smith (1989)ISPC240, daily Schuler (1996)ISPC60am, 120pm40-5010s Rx, 60s rest (10mmHg) McCulloch (1994)IPC60, 2/75090s Rx, 30s rest Kumar (2002)IPC60 x 2 daily, 4 months6090s inflation, 90s deflation Rowland (2000)IPC ?S60 x 2 daily, 2-3 months50 Nikolovska (2005) - fastISPC60, daily,30-450.5s inflation, 6s Rx, 12s deflation Vs. Nikolovska (2005) - slowISPC60, daily,30-4560s inflation, 30s Rx, 90s deflation Ginsberg (1999)IPC ?S20, twice daily50? Kakkos (2000)ISPC?4511s inflation, ?s Rx, 60s deflation Lymphoedema framework (2006)ISPC30-12030-60nil recommended Delis (2000)IPC>240 total per day1803s inflation, 17s deflation Delis (2001)ISPC?1204s inflation, 16s deflation Chleboun (1995)IPC20, daily, 5 days6040s inflation, 20s deflation

6 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

7 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

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

9 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

10 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)

11 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

12 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.

13 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)

14 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.

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

16 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

17 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

18 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!

19 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.

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