Intermittent Compression Devices

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Intermittent CompressionDevices

• Jennifer Doherty-Restrepo, ATC, LAT
• Entry-Level Athletic Training Education Program
• PET 4995 Therapeutic Modalities

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Definitions

• Edema
• Abnormal amounts of fluid in extracellular tissue
  spaces
• Joint swelling
• Blood and/or fluid accumulation
• Appears and feels like a water balloon
• Lymphedema
• Accumulation of lymph in subcutaneous tissues
• Occurs over several hours following injury

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The Lymphatic System

• Pick up plasma and plasma proteins that escape
  from small blood vessels and return them to blood
  circulation
• Acts as a safety valve for fluid overload
• Prevents edema formation
• Maintains homeostasis of extracellular
  environment
• Removes excess protein molecules and waste from
  the interstitial fluid
• Cleanses interstitial fluid
• Blocks thes spread of infection or malignant
  cells

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The Lymphatic System

• Closed vascular system
• Parallels arterial system
• Lymphatic capillaries made of single
  layered endothelial cells

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The Lymphatic System

• Lymphatic capillaries are surrounded by
  interstitial fluid
• Terminal lymphatics provide entry way into
  lymphatic system for excess interstitial fluid
  and plasma proteins

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The Lymphatic System

• Lymphatic capillaries form a network of lymphatic
  vessels
• Lead to larger Collecting Vessels in extremities
  
• Collecting vessels connect with thoracic duct or
  right lymphatic duct, which join the venous
  system

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The Lymphatic System

• Fluid moving into interstitial spaces pushes or
  pulls on fibrils
• Fibrils connective tissue fibers supporting
  lymphatic capillaries
• Endothelial cell junctions in lymphatic capillary
  wall open
• Allows entry of interstitial fluid,
  cellular waste, large protein
  molecules, plasma
  proteins,
  extracellular particles, and
  cells into terminal
  lymphatics

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The Lymphatic System

• Once in the terminal lymphatics, the interstitial
  fluid, cellular waste, large protein molecules,
  plasma proteins, extracellular particles, and
  cells become lymph
• Endothelial cell junctions in lymphatic
  capillaries remain closed when there is
• No increase in interstitial volume
• No tissue activity
• Movement of lymph is accomplished via muscle
  activity, active and passive motion, elevation,
  respiration, and blood vessel contraction

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Injury Edema Pitting Edema

• Local edema
• Formed by plasma, plasma proteins, and cellular
  debris moving into interstitial spaces
• Hormones released by injured cells stimulate
  small anterioles, capillaries and venules to
  vasodialate separating endothelial cells in
  vessel wall
• Increases permeability

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Injury Edema Pitting Edema

• Increased permeability allows more plasma, plasma
  proteins, and cellular debris to escape into
  local area
• Results in gel-like fluid that is trapped by
  collagen fibers
• Gel-like fluid referred to as pitting edema

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Injury Edema Lymphedema

• Accumulation of edema causing overdistention of
  lymph capillaries
• Entry pores become ineffective and interstitial
  fluid increases
• Lymphedema results
• Constriction of lymph capillaries due to
  increased pressure will also discourage lymph
  flow and cause lymphedema formation

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Negative Effects of Edema

• Edema compounds injury by causing secondary
  hypoxic cellular death in surrounding tissues
• Other negative effects include
• Physical separation of torn tissue ends
• Pain
• Restricted joint range of motion
• Prolonged recovery times
• Interstitial fibrosis
• Reflex sympathetic dystrophy

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Treatment of Edema

• P.R.I.C.E.
• Minimize edema
  formation
• E-stim or AROM
  exercises
• Retard edema
  accumulation
• Any treatment that assists lymph flow will
  decrease plasma protein content in interstitial
  spaces and decrease edema

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Treatment of Edema Elevation

• Gravity used to assist lymph flow
• The higher the elevation, the greater the effect
  on the lymph flow

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Treatment of Edema Compression

• Muscle contractions provide rhythmic internal
  compression of lymph vessels to assist lymph flow
• Isometrics, AROM exercise, or E-stim
• External compression assists lymph flow
• Massage, elastic compression, or intermittent
  pressure devices
• External compression spread interstitial edema
  over a larger area, enabling more lymph
  capillaries to become involved in removing plasma
  proteins

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Treatment of Edema Weight-Bearing Exercise

• Activates a venous pump
• Not related to muscle activity
• Mediated by release of an endothelial-derived
  relaxing factor (EDRF)
• EDRF is liberated by sudden pressure changes and
  it diffuses locally
• Functions to relax smooth muscle and stimulate
  blood flow in the veins

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Treatment of Edema Cryotherapy

• Cryotherapy used in conjunction with intermittent
  compression has shown the best results in the
  reduction of post-acute injury edema

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Intermittent Compression Treatment Parameters

• Inflation Pressure
• On/Off Time Sequence
• Total Treatment Time

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Inflation Pressure

• Loosely correlated with BP
• Most treatment protocols utilize a pressure
  approximating diastolic BP

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Inflation Pressure

• Arterial capillary pressures 30 mmHg
• Any pressure that exceeds this should encourage
• Edema absorption, and
• Lymph flow

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Inflation Pressure

• Maximum pressure should correspond to diastolic
  BP
• More pressure is not necessarily better
• Enough pressure is needed to squeeze lymphatic
  vessels and encourage lymph flow

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On/Off Time Sequence

• On/Off time sequences are variable
• Patient comfort should be a primary deciding
  factor
• 30s on, 30s off is effective and comfortable
• Lymphatic massage
• Shorter on/off time sequences may have an
  advantage

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Total Treatment Time

• Clinical studies show significant limb volume
  reduction after 30 minutes of compression
• A treatment of 10 - 30 minutes may be adequate
  unless edema is overwhelming in volume or is
  resistant to treatment
• Multiple treatment times per day may also be an
  advantage in controlling and reducing edema

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Equipment Setup and Instructions

• Compression sleeves
• Half-leg, full-leg, half-arm, or full-arm
• Connect compression sleeve (deflated) to unit via
  a rubber hose and connecting valve

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Equipment Setup and Instructions

• Assess BP and set inflation pressure
• Set On-time (between 30 to 120 seconds)
• Off-time is left at 0 until the compression
  sleeve is inflated and treatment pressure is
  reached
• Then adjust off-time between 0 and 120 seconds
• During the off-time, instruct patient to move
  extremity
• Treatment should last between 20 - 30 minutes

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Cold and Compression Combination

• Combination of cold and compression is effective
  in treating edema
• Cold/compression unit
• Temperature adjustment ranges between 10 - 25oC
• Cooling accomplished by circulating cold water
  through compression sleeve

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Compression and Electrical Stimulating Currents

• Combination of compression and e-stim
  induced muscle pumping is effective in treating
  edema
• Facilitates reabsorption of injury byproducts by
  lymphatic system

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Sequential Compression Pumps

• Sequentially inflate compression sleeves with
  multiple compartments
• Massage effect
• Applies pressure from distal to proximal
• Gradual decrease in pressure gradient

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Sequential Compression Pumps

• Highest pressure in distal compartment sleeve
• Determined by mean value of systolic to diastolic
  BP
• Middle compartment is set at 20 mm lower than the
  distal cell
• Proximal compartment pressure is reduced an
  additional 20 mm

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Sequential Compression Pumps

• Each pressure cycle is 120s
• Distal compartment is pressurized initially and
  continues pressurization for 90s
• 20s later, the middle compartment inflates
• After another 20s, the proximal compartment
  inflates
• A final 30s period allows pressure in all three
  compartments to return to 0
• Entire cycle is then repeated

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Indications

• Lymphedema
• Traumatic edema
• Chronic edema
• Stasis ulcers
• Intermittent claudications
• Postoperatively to reduce the possibility of
  developing a deep vein thrombosis
• Facilitate wound healing following surgery

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Contraindications

• Deep vein thrombosis
• Local superficial infection
• Congestive heart failure
• Acute pulmonary edema
• Displaced fractures
• Cancer