- Email: [email protected]
Effect of elastic compression stockings on venous hemodynamics in hemiplegic patients
JStroke Cerebrovasc Dis 1992;2:196-201 © 1992 National Stroke Association
Effect of Elastic Compression Stockings on Venous Hemodynamics in Hemiplegic Patients 1,3Eulogio Sioson, M.D., 2J. Jeffrey Alexander, M.D., 1,3Asikin Mentari, M.D., 2Ronda Heitz, R.V.T., and 1,3Lorraine Mion, R.M., M.S.N.
Unilateral lower extremity edema and an increased risk of thromboembolism have been associated with hemiplegia following stroke. This study was undertaken to determine the effect of knee-high, graded elastic stockings on venous hemodynamics in hemiplegic patients. Thirty-six patients with recent cerebral infarcts were studied. The presence of underlying venous or arterial occlusive disease was excluded in all patients. Duplex scanning techniques were used to measure femoral and popliteal venous circumference, cross-sectional area, and peak flow velocity in the normal and paralyzed extremities both with and without stockings. All patients were examined and assessed for the degree of motor weakness and Brunnstrom stage of recovery. Associated medical illnesses were also reviewed. These patients were found to have a decreased flow in the femoral (p = 0.0002) and popliteal (p = 0.006) veins and an increase in the femoral vein size. The application of compression stockings resulted in a significant increase in venous size and flow velocity in both areas. The femoral and popliteal velocity correlated inversely with the degree of motor impairment and Brunnstrom stage, suggesting that factors other than the muscle pump may be responsible for the augmentation of femoral flow velocity in the paralyzed leg. There was no correlation demonstrated with other variables such as age, gender, cardiovascular disease, or diabetes. These results would indicate a potential benefit of graded knee-high elastic compression stockings in reducing venous flow stasis in herniparetic patients. Key Words: Stroke-Deep vein thrombosis-Graded elastic compression stockings.
Unilateral extremity edema and discoloration are frequently associated with hemiparesis. Although these findings have been attributed to autonomic dysfunction (1,2), venous flow stasis secondary to loss of muscle pump function (3), or local changes in capil-
From the Departments of IMedicine, 2Surgery, and 3Physical Medicine and Rehabilitation, Case Western Reserve University and MetroHealth Medical Center, Cleveland, OH, U.S.A. Address correspondence and reprint requests to Dr. J. J. Alexander at Department of Surgery, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH 44109, U.S.A. 196
JSTROKE CEREBROVASCDIS, VOL. 2, NO.4, 1992
lary permeability and lymphatic clearance (4), their true etiology remains undetermined. Alterations in venous hemodynamics in the paralyzed extremity include a reduction in venous flow velocity (5,6), which has been correlated with an increased risk of deep venous thrombosis (7-10) and pulmonary embolism (11,12). Various methods of prophylaxis have been employed to minimize venous flow stasis and reduce the incidence of thromboembolism. In susceptible patients, the use of graduated elastic compression stockings has been shown to augment venous flow velocity (13-15), and decrease thromboembolic disease (1619). Therefore, it has become accepted as a safe and
COMPRESSIONSTOCKINGS INHEMIPLEGIC PATIENTS
effective means of prophylaxis in such patients, particularly when the cost and risks of other methods preclude their use. The apparent benefits of elastic compression stockings have not been documented for hemiplegic patients, in whom venous flow stasis might be expected to be more profound and prolonged. This preliminary study was undertaken to define the hemodynamic changes that occur in the paralyzed extremity, and to determine the potential effect of knee-high graduated elastic compressive stockings on venous flow characteristics in the hemiplegic patient.
Methods Duplex scanning was used to measure vein size and peak venous flow velocity in the normal and paralyzed extremities of hemiplegic patients. These measurements were then repeated following the application of graduated elastic compression stockings. Selected patients were placed in a supine position in a quiet room with constant ambient temperature. Normal arterial circulation was first confirmed by pulse examination, and by standard Doppler pressure and waveform criteria (20). The absence of venous insufficiency was documented by physical examination, whereas that of venous obstruction was determined using Doppler flow studies (21) and impedance plethysmography (22). After a IS-min rest period, the common femoral and popliteal veins of the normal and affected extremities were alternately scanned using a Diasonics DRF 400 duplex scanner with a 7.5 MHz probe. Measurements of venous area and circumference were taken from transverse ultrasound images. Peak flow velocity was derived from the Doppler frequency obtained from the central portion of each vein during quiet respiration. All measurements were made in triplicate and the mean value calculated. Knee-high graduated elastic compression hose (TED) were then placed on both legs and, after an additional IS-min rest period, venous size and flow measurements were repeated. All patients were independently assessed for the degree of motor weakness with grading of both proximal and distal muscle strength on a scale of 0-5, and staging of the degree of recovery according to the Brunnstrom scale (23). Venous size and flow data were analyzed using a paired Student's t test, whereas multivariate associations were examined using multiple regression models. A p value of less than 0.05 was accepted as representing statistical significance.
Results Thirty-six patients having suffered unilateral cerebral infarcts within 30 days were included in this study. This group was comprised of 17 (47%) men and 19 (53%) women, with a mean age of 65.4 years and an age range of 48-82 years. Twenty-seven (75%) patients were hypertensive, 14 (39%) were diabetic, 10 (28%) had documented cardiovascular disease, and 2 (6%) had chronic obstructive pulmonary disease. No patients had evidence of venous obstruction or insufficiency, nor did they have measurable peripheral vascular occlusive disease, as evidenced by a mean (±SD) ankle-brachial index of 1.28 ± 0.20 in the affected extremity and 1.21 ± 2.7 in the paralyzed extremity. Independent evaluation of motor' impairment showed that 21 (58%) patients had a left hemiparesis, whereas the right side was affected in the remaining 15 (42%) patients. More than half of the patients had marked distal muscle weakness, with muscle strength of grade 0 or 1 (Table 1). Similarly, 24 (67%) patients were classified a Brunnstrom Stage 1 or 2 (Table 2). The cross-sectional area, circumference, and peak flow velocity of the femoral and popliteal veins were measured in the normal and paralyzed lower extremities both with and without stockings. In the popliteal area (Table 3), there was no significant difference in size between the normal and hemplegic legs. However, peak venous flow velocity was reduced in the hemiplegic leg (p, 0.006). The application of support hose resulted in an increase in venous size both in the normal and paralyzed extremity as well as an increase in peak venous flow velocity. This effect was suffi-
Table 1.
Musclestrengih' assessment Proximal
Distal
Grade
Description
No. (%)
No. (%)
0 1
Absent: No movement Trace: Palpable muscle contraction; no movement Poor: Movement without gravity Fair: Movement against gravity Good: Movement against moderate resistance Normal: Movement against maximal resistance
14 (39)
17 (47)
2 (6)
3 (8)
13 (36)
9 (25)
5 (14)
5 (14)
2 (6)
2 (6)
0(-)
0(-)
2 3 4
5
J STROKECEREBROVASCDIS, VOL.2, NO.4, 1992
197
£ SIOSON IT AL
Table 2.
Brunnsirom stage of recovery
Stage
Description
No. ('Yo)
1 2 3
Flaccid Minimal spasticity and weak synergy Moderate spasticity with minimal to moderate synergy Minimal/moderate synergy pattern with minimal isolated movement Minimal spasticity/minimal synergy and moderate voluntary movement Good voluntary movement with minimal or no spasticity
9 (25) 15 (42)
4 5
6
apparent correlation between flow measurements in the paralyzed leg and patient age (r = 0.16), gender (r = -0.06), or the presence of cardiac disease (r = - 0.23) , hypertension (r = - 0.10), pulmonary disease (r = 0.00), or diabetes (r = 0.01).
11 (31)
Discussion
1 (3)
0(-) 0(-)
cient to increase flow velocity in the paralyzed limb to a level statistically equivalent to the normal leg. At thefemoral level (Table 4), hemiplegia led to an increase 'in venous size and a reduction in peak flow velocity (p = 0.0002). This relationship between the normal and paralyzed leg was maintained despite the application of knee-high support hose. However, stockings did increase both venous size and peak flow velocity in the normal and affected extremities, so that the flow velocity in the paralyzed leg with the stocking reached that of the normal leg without the stocking. Correlation between the degree of motor impairment and venous flow capacity was made using regression analysis (Table 5). In the femoral area, there appeared to be an inverse relationship between proximal muscle strength, Brunnstrom staging and peak flow velocity, which was not altered by the application of support stockings. A similar trend was seen with distal muscle strength, although this did not reach statistical significance. No correlation between the functional parameters and venous flow velocity was seen in the popliteal region. In addition, there was no
Table 3.
Stroke has been shown to result in reduced venous flow velocity in the hemiplegic extremity (5,6) and a concomitant increase in the incidence of venous thromboembolic disease (11,12). The role of stasis in the pathogenesis of thrombosis was clearly delineated by Virchow more than a century ago. This role has been further emphasized by Hunter and others (2426), who concluded that prolonged immobility contributed more to the development of venous thrombosis than other recognized risk factors including trauma, surgical treatment, a history of thromboembolism, obesity, age, and malignancy. It has been postulated that this is related to the reduction in blood flow velocity, which has been found to occur in bedridden patients (27), and presumed due to a reduction in calf pump function . This same phenomenon is perhaps more apparent in hemiplegic patients, where loss of extremity activity may be profound and prolonged. Warlow and others (7,9) have demonstrated an incidence of venous thrombosis in excess of 50% in association with acute paralysis, whereas Cope et al. (10) have provided radiographic evidence of deep venous thrombosis in 33% of chronically paralyzed extremities. Not unexpectedly, these patients are at greater risk for pulmonary embolism (11,12), with most emboli originating from the paretic lower extremity (5,11). The prophylaxis of deep venous thrombosis has generally been directed toward either the inhibition of coagulation or the prevention of flow stasis (16).
Popliteal uein measurements'
Normal leg With stocking
Without stocking Area (em? ± SO) Circumference (cm ± SO) Peak flow velocity (cm/s ± SO)
0.49 2.66 13.37
± 0.19 ± 0.54 ± 3.20 b
Hemiplegic leg
0.59 2.86 15.94
aN, 36; SD, standard deviation. 0.006. "p = 0.03.
'v =
198 ] STROKE CEREBROVASC DIS, VOL. 2, NO.4, 1992
± 0.23 ± 0.66< ± 3.61
p
Without stocking
With stocking
p
0.0001 0.0003 0.0001
0.53 ± 0.20 2.74 ± 0.56 11.74 ± 2.76b
0.62 ± 0.25 3.03 ± 0.63< 14.89 ± 4.09
0.0001 0.0001 0.0001
COMPRESSIONSTOCKINGSIN HEMIPLEGIC PATIENTS
Table 4.
Femoral veinmeasurements"
Normal leg Without stocking Area (em? ± SO) Circumference (cm ± SO) Peak flow velocity (cm/s ± SO)
1.03 3.74 19.06
Hemiplegic leg
With stocking
± 0.39b ± 0.64' ± 4.88d
1.14 4.00 21.39
Without stocking
p
± 0.44' ± 0.79f ± 5.98
1.16 4.11 17.03
0.005 0.0002 0.0001
With stocking
± 0.45b ± 0.79' ± 4.44d
1.29 4.29 20.03
± 0.45' ± o.zs' ± 6.61
p 0.005 0.009 0.0001
aN, 36.
'v =
0.01.
Z:: 0.0001. p - 0.0004.
'p = 0.002. f p = 0.0002.
Whereas various methods of prophylaxis have been shown to be effective in postoperative patients (28), similar studies in the stroke patients are unavailable. In this patient population, reluctance to consider standard measures of anticoagulation or intermittent pneumatic compression have been based on concerns regarding the risks of anticoagulation, cost, and the need for prolonged administration under proper medical supervision. The use of graduated elastic compression stockings has been shown to have a beneficial effect on the reduction of venous thromboembolism in susceptible patients (16-19,29). Although the means by which this occurs is unclear, there is evidence to suggest that extrinsic compression of the leg results in a decrease in the venous volume of the extremity and an acceleration of venous blood flow (13-15,17,30,31), thereby allowing a more rapid clearance of blood from behind venous sinusoids, where early clot formation is believed to occur (32-34). Their effectiveness has been shown to be somewhat less than that of intermittent pneumatic compression devices (35,36),and yet their cost, ease of application, and continuous benefit pro-
vide obvious advantages. Whether this same benefit occurs in stroke patients, however, is unclear. Duplex scanning has previously been shown to be helpful in the assessment of venous anatomy and physiology and has allowed the direct measurement of venous circumference, cross-sectional area, and flow velocity (37). In the present study, it was used to quantitate venous size and flow velocity in the femoral and popliteal veins of hemiplegic patients with and without extrinsic compression of the extremity. In this manner, the normal extremity served as a control, minimizing the potential contribution of systemic factors to the hemodynamic measurements. The results obtained indicate that hemiparesis is associated with a reduction in the peak femoral and popliteal venous flow velocity of the affected leg. This reduction was associated with an increase in venous circumference and area, implying a condition of venous stasis. A negative correlation between femoral flow velocity, muscle strength, and Brunnstrom stage would suggest that factors other than the muscle pump may be responsible for the augmentation of femoral flow velocity in the paralyzed leg. This re-
Table 5. Association of peak vellous flow velocity ill hemiplegic leg Femoral
,. Proximal strength Distal strength Brunnstrom stage
Popliteal
Without stocking
-0.40 -0.32 -0.35
With stocking
Without stocking
With stocking
p
r
p
r
p
r
p
0.02 NS 0.03
-0.39 -0.30 -0.37
0.02 NS 0.03
-0.24 -0.07 -0.15
NS NS NS
-0.27 -0.12 -0.16
NS NS NS
"r, Pearson's coefficient of correlation.
J STROKECEREBROVASCDIS, VOL.2, NO.4, 1992
199
E. SIOSON ET AL.
lationship was not apparent in the popliteal region, where calf muscle function might be expected to have a more direct impact on venous flow characteristics. The application of elastic support stockings increased the femoral and popliteal venous size and flow velocity in both the normal and hemiplegic legs. The velocity of venous flow in the hemiplegic leg with the stocking was found to surpass that of the normal leg without the stocking, although the difference between these two values was not statistically significant. Such findings are contrary to the belief expressed by Stanton et al. (13) that external compression increases venous velocity by reducing venous size. However, they are consistent with the belief that extrinsic compression may allow more effective channeling of blood from the superficial to the deep venous system (38,39). This could reduce the total venous volume of the leg while increasing both size and flow velocity of the deep veins. The resultant decrease in flow stasis might be expected to yield a lower incidence of venous thromboembolism. However, further study will be required to determine the clinical value of graduated compressive stockings in the prophylaxis of venous thrombosis in hemiplegic patients.
References 1. Hoerner EF, Dasco MM, McKeown J, et al. Altered vasomotor changes in hemiplegias. Angiology 1954; 5:414-524. 2. Redisch W, Tangco FT, Wertheimer L, et al. Vasomotor responses in the extremities of subjects with various neurologic lesions. Circulation 1957;15:518-24. 3. laBan MM, Johnson EW. Velocity of blood flow in the saphenous vein of hemiplegic patients. Arch Phys Med ReJzabi/1965;46:245-9. 4. Exteon-Smith AN, Crockett DJ. Nature of oedema in paralyzed limbs of hemiplegic patients. Br Med 11957; 2:1280-3. 5. Wright HP, Osborn SB. Venous velocity in bedridden medical patients. Lancet 1952;1:699-700. 6. Alexander H, Sioson E, Heitz R, Mion L Alterations of venous flow in hemiparetic patients. Vasc Surg 1991; 1:433-40. 7. Warlow C, Ogston D, Douglas AS. Venous thrombosis following strokes. Lancet 1972;1:1305-6. 8. Warlow C, Ogston D, Douglas AS. Deep venous thrombosis of the legs after strokes. Br Med 1 1976; 1:1178-83. 9. Gibberd FB, Gould SR, Marks P. Incidence of deep vein thrombosis and leg oedema in patients with strokes. 1 Neurol Neurosurg Psychiatry 1976;39:12225. 10. Cope C, Reyes TM, Skversky NJ. Phlebographic analysis of the incidence of thrombosis in hemiplegia. Radiology 1973;109:581-4. 11. Byren H, Oneil EE. Fatal pulmonary emboli. Am1Surg 1952;83:47-9.
200
1STROKE CEREBROVASC DIS, VOL.2, NO.4, 1992
12. Coon WW. Risk factors in pulmonary embolism. Surg Gynecol Obstet 1965;143:385-90. 13. Stanton JR, Freis ED, Wilkins RW. The acceleration of linear flow in the deep veins of the lower extremity of many by local compression. 1 Clin Invest 1949;28: 553-8. 14. Myerowitz BR, Nelson R. Measurement of the velocity of blood in lower limb veins with and without compression. Surgery 1964;56:481-6. 15. Makin GS, Mayes FB, Holroyd AM. Studies on the effect of "tubigrip" on flow in the deep veins of the calf. Br 1Surg 1969;56:369-72. 16. Scurr JH, Ibrahim SZ, Faber RG, LeQuesne LP. The efficacy of graduated compression stockings in the prevention of deep vein thrombosis. Br 1 Surg 1977; 64:371-3. 17. Wilkins RW, Mixter G [r, Stanton JR Litter J. Elastic stockings in the prevention of pulmonary embolism: a preliminary report. N Engl 1 Med 1952;246:360-4. 18. Holford CP. The effect of graduated static compression on isotopically diagnosed deep vein thrombosis of the leg. Br 1Surg 1976;63:157. 19. Wilkins RW, Stanton JR. Elastic stockings in the prevention of pulmonary embolism. A progress report. N Engl 1Med 1953;248:1087-90. 20. Yao JST. New techniques in objective arterial evaluation. Arch Surg 1973;106:600-4. 21. Strand ness DE, Sumner DS. Ultrasonic velocity detector in the diagnosis of thrombophlebitis. Arch Surg 1972;104:180-3. 22. Hull R VanAken WG, Hirsch J, et al. Impedance plethysmography using occlusive cuff technique in the diagnosis of venous thrombosis. Circulation 1976; 53:696-700. 23. Brunnstrom S. Movement therapy in hemiplegia. New York: Harper & Row, 1970. 24. Hunter WC, Sneeden VD,Robertson TD, Snyder GAC. Thrombosis of the deep veins of the leg. Arch Intern Med 1941;68:1-17. 25. Husni EA, Ximenes JOC, Goyette EM. Elastic support of the lower limbs in hospital patients. lAMA 1970; 214:1456-62. 26. Gibbs NM. Venous thrombosis of the lower limbs with particular reference to bed rest. Br1Surg 1957;45:20936. 27. Wright HP, Osborn SB, Edmonds DG. Effect of postoperative bed rest and early ambulation on the rate of venous blood flow. Lancet 1951;1:22-5. 28. Consensus Conference: Prevention of venous thrombosis and pulmonary embolism. lAMA1986;256:7449. 29. Allan A, Williams JT, Bolton JP, LeQuesne LP. The use of graduated compression stockings in the prevention of postoperative deep vein thrombosis. Br 1Surg 1983; 70:172-4. 30. Myerowitz BR,Crook A. Elastic-stocking compression and venous blood-flow. Effect in the lower limb. Lancet 1960;1:122-4. 31. Paulsen PF, Creech 0 Jr, DeBakey ME. Observations on the venous circulation time in the lower extremities: effect of elevation and compression bandages. Surg Forum 1954;5:137-43. 32. Sigel B, Edelstein AL, Felix WR Jr, Memhart CR. Compression of the deep venous system of the lower leg
COMPRESSION STOCKlNGS IN HEMIPLEGIC PATIENTS
33.
34.
35.
36.
during inactive recumbency. Areh Surg 1973;106:3843. Lewis CE [r, Antoine J, Mueller C, et al. Elastic compression in the prevention of venous stasis. Alii ] Surg 1976;132:739-43. Sigel B, Edelstein AL, Savitch L, et al. Type of compression of reducing venous stasis. Areh Surg 1975; 110:171-5. Borow M, Goldstein H. Postoperative venous thrombosis . Evaluat ion of five methods of treatment. Alii ] Surg 1981;141:2 45-51. Caprini ]A, Chucker JL, Zuckerman L,et al. Thrombo-
sis prophylaxis using external compression. Surg Gyneeol Obslet 1983;156:599-604 . 37. Moneta GL, Bedford G, Beach K, Strandness DE. Duplex ultrasound assessment of venous diameters, peak velocities, and flow patterns. I Vase Surg 1988;8:28691. 38. Christopoulos DG, Nicolaides AN, Szendro G, Irvine AT, Bull M, Eastcott HHG . Air-plethysmography and the effect of elastic compression on venous hemodynamics of the leg. ] Vase Surg 1987;5:148-59 . 39. Mayberry JC, Moneta GL, DeFrang RD,Port er JM. The influence of elastic compression stockings on deep venous hemodynamics. ] Vase Surg 1991;13:91-100.
] STROKE CEREBROVASC DIS, VOL. 2, NO.4, 1992
201
Effect of Elastic Compression Stockings on Venous Hemodynamics in Hemiplegic Patients 1,3Eulogio Sioson, M.D., 2J. Jeffrey Alexander, M.D., 1,3Asikin Mentari, M.D., 2Ronda Heitz, R.V.T., and 1,3Lorraine Mion, R.M., M.S.N.
Unilateral lower extremity edema and an increased risk of thromboembolism have been associated with hemiplegia following stroke. This study was undertaken to determine the effect of knee-high, graded elastic stockings on venous hemodynamics in hemiplegic patients. Thirty-six patients with recent cerebral infarcts were studied. The presence of underlying venous or arterial occlusive disease was excluded in all patients. Duplex scanning techniques were used to measure femoral and popliteal venous circumference, cross-sectional area, and peak flow velocity in the normal and paralyzed extremities both with and without stockings. All patients were examined and assessed for the degree of motor weakness and Brunnstrom stage of recovery. Associated medical illnesses were also reviewed. These patients were found to have a decreased flow in the femoral (p = 0.0002) and popliteal (p = 0.006) veins and an increase in the femoral vein size. The application of compression stockings resulted in a significant increase in venous size and flow velocity in both areas. The femoral and popliteal velocity correlated inversely with the degree of motor impairment and Brunnstrom stage, suggesting that factors other than the muscle pump may be responsible for the augmentation of femoral flow velocity in the paralyzed leg. There was no correlation demonstrated with other variables such as age, gender, cardiovascular disease, or diabetes. These results would indicate a potential benefit of graded knee-high elastic compression stockings in reducing venous flow stasis in herniparetic patients. Key Words: Stroke-Deep vein thrombosis-Graded elastic compression stockings.
Unilateral extremity edema and discoloration are frequently associated with hemiparesis. Although these findings have been attributed to autonomic dysfunction (1,2), venous flow stasis secondary to loss of muscle pump function (3), or local changes in capil-
From the Departments of IMedicine, 2Surgery, and 3Physical Medicine and Rehabilitation, Case Western Reserve University and MetroHealth Medical Center, Cleveland, OH, U.S.A. Address correspondence and reprint requests to Dr. J. J. Alexander at Department of Surgery, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH 44109, U.S.A. 196
JSTROKE CEREBROVASCDIS, VOL. 2, NO.4, 1992
lary permeability and lymphatic clearance (4), their true etiology remains undetermined. Alterations in venous hemodynamics in the paralyzed extremity include a reduction in venous flow velocity (5,6), which has been correlated with an increased risk of deep venous thrombosis (7-10) and pulmonary embolism (11,12). Various methods of prophylaxis have been employed to minimize venous flow stasis and reduce the incidence of thromboembolism. In susceptible patients, the use of graduated elastic compression stockings has been shown to augment venous flow velocity (13-15), and decrease thromboembolic disease (1619). Therefore, it has become accepted as a safe and
COMPRESSIONSTOCKINGS INHEMIPLEGIC PATIENTS
effective means of prophylaxis in such patients, particularly when the cost and risks of other methods preclude their use. The apparent benefits of elastic compression stockings have not been documented for hemiplegic patients, in whom venous flow stasis might be expected to be more profound and prolonged. This preliminary study was undertaken to define the hemodynamic changes that occur in the paralyzed extremity, and to determine the potential effect of knee-high graduated elastic compressive stockings on venous flow characteristics in the hemiplegic patient.
Methods Duplex scanning was used to measure vein size and peak venous flow velocity in the normal and paralyzed extremities of hemiplegic patients. These measurements were then repeated following the application of graduated elastic compression stockings. Selected patients were placed in a supine position in a quiet room with constant ambient temperature. Normal arterial circulation was first confirmed by pulse examination, and by standard Doppler pressure and waveform criteria (20). The absence of venous insufficiency was documented by physical examination, whereas that of venous obstruction was determined using Doppler flow studies (21) and impedance plethysmography (22). After a IS-min rest period, the common femoral and popliteal veins of the normal and affected extremities were alternately scanned using a Diasonics DRF 400 duplex scanner with a 7.5 MHz probe. Measurements of venous area and circumference were taken from transverse ultrasound images. Peak flow velocity was derived from the Doppler frequency obtained from the central portion of each vein during quiet respiration. All measurements were made in triplicate and the mean value calculated. Knee-high graduated elastic compression hose (TED) were then placed on both legs and, after an additional IS-min rest period, venous size and flow measurements were repeated. All patients were independently assessed for the degree of motor weakness with grading of both proximal and distal muscle strength on a scale of 0-5, and staging of the degree of recovery according to the Brunnstrom scale (23). Venous size and flow data were analyzed using a paired Student's t test, whereas multivariate associations were examined using multiple regression models. A p value of less than 0.05 was accepted as representing statistical significance.
Results Thirty-six patients having suffered unilateral cerebral infarcts within 30 days were included in this study. This group was comprised of 17 (47%) men and 19 (53%) women, with a mean age of 65.4 years and an age range of 48-82 years. Twenty-seven (75%) patients were hypertensive, 14 (39%) were diabetic, 10 (28%) had documented cardiovascular disease, and 2 (6%) had chronic obstructive pulmonary disease. No patients had evidence of venous obstruction or insufficiency, nor did they have measurable peripheral vascular occlusive disease, as evidenced by a mean (±SD) ankle-brachial index of 1.28 ± 0.20 in the affected extremity and 1.21 ± 2.7 in the paralyzed extremity. Independent evaluation of motor' impairment showed that 21 (58%) patients had a left hemiparesis, whereas the right side was affected in the remaining 15 (42%) patients. More than half of the patients had marked distal muscle weakness, with muscle strength of grade 0 or 1 (Table 1). Similarly, 24 (67%) patients were classified a Brunnstrom Stage 1 or 2 (Table 2). The cross-sectional area, circumference, and peak flow velocity of the femoral and popliteal veins were measured in the normal and paralyzed lower extremities both with and without stockings. In the popliteal area (Table 3), there was no significant difference in size between the normal and hemplegic legs. However, peak venous flow velocity was reduced in the hemiplegic leg (p, 0.006). The application of support hose resulted in an increase in venous size both in the normal and paralyzed extremity as well as an increase in peak venous flow velocity. This effect was suffi-
Table 1.
Musclestrengih' assessment Proximal
Distal
Grade
Description
No. (%)
No. (%)
0 1
Absent: No movement Trace: Palpable muscle contraction; no movement Poor: Movement without gravity Fair: Movement against gravity Good: Movement against moderate resistance Normal: Movement against maximal resistance
14 (39)
17 (47)
2 (6)
3 (8)
13 (36)
9 (25)
5 (14)
5 (14)
2 (6)
2 (6)
0(-)
0(-)
2 3 4
5
J STROKECEREBROVASCDIS, VOL.2, NO.4, 1992
197
£ SIOSON IT AL
Table 2.
Brunnsirom stage of recovery
Stage
Description
No. ('Yo)
1 2 3
Flaccid Minimal spasticity and weak synergy Moderate spasticity with minimal to moderate synergy Minimal/moderate synergy pattern with minimal isolated movement Minimal spasticity/minimal synergy and moderate voluntary movement Good voluntary movement with minimal or no spasticity
9 (25) 15 (42)
4 5
6
apparent correlation between flow measurements in the paralyzed leg and patient age (r = 0.16), gender (r = -0.06), or the presence of cardiac disease (r = - 0.23) , hypertension (r = - 0.10), pulmonary disease (r = 0.00), or diabetes (r = 0.01).
11 (31)
Discussion
1 (3)
0(-) 0(-)
cient to increase flow velocity in the paralyzed limb to a level statistically equivalent to the normal leg. At thefemoral level (Table 4), hemiplegia led to an increase 'in venous size and a reduction in peak flow velocity (p = 0.0002). This relationship between the normal and paralyzed leg was maintained despite the application of knee-high support hose. However, stockings did increase both venous size and peak flow velocity in the normal and affected extremities, so that the flow velocity in the paralyzed leg with the stocking reached that of the normal leg without the stocking. Correlation between the degree of motor impairment and venous flow capacity was made using regression analysis (Table 5). In the femoral area, there appeared to be an inverse relationship between proximal muscle strength, Brunnstrom staging and peak flow velocity, which was not altered by the application of support stockings. A similar trend was seen with distal muscle strength, although this did not reach statistical significance. No correlation between the functional parameters and venous flow velocity was seen in the popliteal region. In addition, there was no
Table 3.
Stroke has been shown to result in reduced venous flow velocity in the hemiplegic extremity (5,6) and a concomitant increase in the incidence of venous thromboembolic disease (11,12). The role of stasis in the pathogenesis of thrombosis was clearly delineated by Virchow more than a century ago. This role has been further emphasized by Hunter and others (2426), who concluded that prolonged immobility contributed more to the development of venous thrombosis than other recognized risk factors including trauma, surgical treatment, a history of thromboembolism, obesity, age, and malignancy. It has been postulated that this is related to the reduction in blood flow velocity, which has been found to occur in bedridden patients (27), and presumed due to a reduction in calf pump function . This same phenomenon is perhaps more apparent in hemiplegic patients, where loss of extremity activity may be profound and prolonged. Warlow and others (7,9) have demonstrated an incidence of venous thrombosis in excess of 50% in association with acute paralysis, whereas Cope et al. (10) have provided radiographic evidence of deep venous thrombosis in 33% of chronically paralyzed extremities. Not unexpectedly, these patients are at greater risk for pulmonary embolism (11,12), with most emboli originating from the paretic lower extremity (5,11). The prophylaxis of deep venous thrombosis has generally been directed toward either the inhibition of coagulation or the prevention of flow stasis (16).
Popliteal uein measurements'
Normal leg With stocking
Without stocking Area (em? ± SO) Circumference (cm ± SO) Peak flow velocity (cm/s ± SO)
0.49 2.66 13.37
± 0.19 ± 0.54 ± 3.20 b
Hemiplegic leg
0.59 2.86 15.94
aN, 36; SD, standard deviation. 0.006. "p = 0.03.
'v =
198 ] STROKE CEREBROVASC DIS, VOL. 2, NO.4, 1992
± 0.23 ± 0.66< ± 3.61
p
Without stocking
With stocking
p
0.0001 0.0003 0.0001
0.53 ± 0.20 2.74 ± 0.56 11.74 ± 2.76b
0.62 ± 0.25 3.03 ± 0.63< 14.89 ± 4.09
0.0001 0.0001 0.0001
COMPRESSIONSTOCKINGSIN HEMIPLEGIC PATIENTS
Table 4.
Femoral veinmeasurements"
Normal leg Without stocking Area (em? ± SO) Circumference (cm ± SO) Peak flow velocity (cm/s ± SO)
1.03 3.74 19.06
Hemiplegic leg
With stocking
± 0.39b ± 0.64' ± 4.88d
1.14 4.00 21.39
Without stocking
p
± 0.44' ± 0.79f ± 5.98
1.16 4.11 17.03
0.005 0.0002 0.0001
With stocking
± 0.45b ± 0.79' ± 4.44d
1.29 4.29 20.03
± 0.45' ± o.zs' ± 6.61
p 0.005 0.009 0.0001
aN, 36.
'v =
0.01.
Z:: 0.0001. p - 0.0004.
'p = 0.002. f p = 0.0002.
Whereas various methods of prophylaxis have been shown to be effective in postoperative patients (28), similar studies in the stroke patients are unavailable. In this patient population, reluctance to consider standard measures of anticoagulation or intermittent pneumatic compression have been based on concerns regarding the risks of anticoagulation, cost, and the need for prolonged administration under proper medical supervision. The use of graduated elastic compression stockings has been shown to have a beneficial effect on the reduction of venous thromboembolism in susceptible patients (16-19,29). Although the means by which this occurs is unclear, there is evidence to suggest that extrinsic compression of the leg results in a decrease in the venous volume of the extremity and an acceleration of venous blood flow (13-15,17,30,31), thereby allowing a more rapid clearance of blood from behind venous sinusoids, where early clot formation is believed to occur (32-34). Their effectiveness has been shown to be somewhat less than that of intermittent pneumatic compression devices (35,36),and yet their cost, ease of application, and continuous benefit pro-
vide obvious advantages. Whether this same benefit occurs in stroke patients, however, is unclear. Duplex scanning has previously been shown to be helpful in the assessment of venous anatomy and physiology and has allowed the direct measurement of venous circumference, cross-sectional area, and flow velocity (37). In the present study, it was used to quantitate venous size and flow velocity in the femoral and popliteal veins of hemiplegic patients with and without extrinsic compression of the extremity. In this manner, the normal extremity served as a control, minimizing the potential contribution of systemic factors to the hemodynamic measurements. The results obtained indicate that hemiparesis is associated with a reduction in the peak femoral and popliteal venous flow velocity of the affected leg. This reduction was associated with an increase in venous circumference and area, implying a condition of venous stasis. A negative correlation between femoral flow velocity, muscle strength, and Brunnstrom stage would suggest that factors other than the muscle pump may be responsible for the augmentation of femoral flow velocity in the paralyzed leg. This re-
Table 5. Association of peak vellous flow velocity ill hemiplegic leg Femoral
,. Proximal strength Distal strength Brunnstrom stage
Popliteal
Without stocking
-0.40 -0.32 -0.35
With stocking
Without stocking
With stocking
p
r
p
r
p
r
p
0.02 NS 0.03
-0.39 -0.30 -0.37
0.02 NS 0.03
-0.24 -0.07 -0.15
NS NS NS
-0.27 -0.12 -0.16
NS NS NS
"r, Pearson's coefficient of correlation.
J STROKECEREBROVASCDIS, VOL.2, NO.4, 1992
199
E. SIOSON ET AL.
lationship was not apparent in the popliteal region, where calf muscle function might be expected to have a more direct impact on venous flow characteristics. The application of elastic support stockings increased the femoral and popliteal venous size and flow velocity in both the normal and hemiplegic legs. The velocity of venous flow in the hemiplegic leg with the stocking was found to surpass that of the normal leg without the stocking, although the difference between these two values was not statistically significant. Such findings are contrary to the belief expressed by Stanton et al. (13) that external compression increases venous velocity by reducing venous size. However, they are consistent with the belief that extrinsic compression may allow more effective channeling of blood from the superficial to the deep venous system (38,39). This could reduce the total venous volume of the leg while increasing both size and flow velocity of the deep veins. The resultant decrease in flow stasis might be expected to yield a lower incidence of venous thromboembolism. However, further study will be required to determine the clinical value of graduated compressive stockings in the prophylaxis of venous thrombosis in hemiplegic patients.
References 1. Hoerner EF, Dasco MM, McKeown J, et al. Altered vasomotor changes in hemiplegias. Angiology 1954; 5:414-524. 2. Redisch W, Tangco FT, Wertheimer L, et al. Vasomotor responses in the extremities of subjects with various neurologic lesions. Circulation 1957;15:518-24. 3. laBan MM, Johnson EW. Velocity of blood flow in the saphenous vein of hemiplegic patients. Arch Phys Med ReJzabi/1965;46:245-9. 4. Exteon-Smith AN, Crockett DJ. Nature of oedema in paralyzed limbs of hemiplegic patients. Br Med 11957; 2:1280-3. 5. Wright HP, Osborn SB. Venous velocity in bedridden medical patients. Lancet 1952;1:699-700. 6. Alexander H, Sioson E, Heitz R, Mion L Alterations of venous flow in hemiparetic patients. Vasc Surg 1991; 1:433-40. 7. Warlow C, Ogston D, Douglas AS. Venous thrombosis following strokes. Lancet 1972;1:1305-6. 8. Warlow C, Ogston D, Douglas AS. Deep venous thrombosis of the legs after strokes. Br Med 1 1976; 1:1178-83. 9. Gibberd FB, Gould SR, Marks P. Incidence of deep vein thrombosis and leg oedema in patients with strokes. 1 Neurol Neurosurg Psychiatry 1976;39:12225. 10. Cope C, Reyes TM, Skversky NJ. Phlebographic analysis of the incidence of thrombosis in hemiplegia. Radiology 1973;109:581-4. 11. Byren H, Oneil EE. Fatal pulmonary emboli. Am1Surg 1952;83:47-9.
200
1STROKE CEREBROVASC DIS, VOL.2, NO.4, 1992
12. Coon WW. Risk factors in pulmonary embolism. Surg Gynecol Obstet 1965;143:385-90. 13. Stanton JR, Freis ED, Wilkins RW. The acceleration of linear flow in the deep veins of the lower extremity of many by local compression. 1 Clin Invest 1949;28: 553-8. 14. Myerowitz BR, Nelson R. Measurement of the velocity of blood in lower limb veins with and without compression. Surgery 1964;56:481-6. 15. Makin GS, Mayes FB, Holroyd AM. Studies on the effect of "tubigrip" on flow in the deep veins of the calf. Br 1Surg 1969;56:369-72. 16. Scurr JH, Ibrahim SZ, Faber RG, LeQuesne LP. The efficacy of graduated compression stockings in the prevention of deep vein thrombosis. Br 1 Surg 1977; 64:371-3. 17. Wilkins RW, Mixter G [r, Stanton JR Litter J. Elastic stockings in the prevention of pulmonary embolism: a preliminary report. N Engl 1 Med 1952;246:360-4. 18. Holford CP. The effect of graduated static compression on isotopically diagnosed deep vein thrombosis of the leg. Br 1Surg 1976;63:157. 19. Wilkins RW, Stanton JR. Elastic stockings in the prevention of pulmonary embolism. A progress report. N Engl 1Med 1953;248:1087-90. 20. Yao JST. New techniques in objective arterial evaluation. Arch Surg 1973;106:600-4. 21. Strand ness DE, Sumner DS. Ultrasonic velocity detector in the diagnosis of thrombophlebitis. Arch Surg 1972;104:180-3. 22. Hull R VanAken WG, Hirsch J, et al. Impedance plethysmography using occlusive cuff technique in the diagnosis of venous thrombosis. Circulation 1976; 53:696-700. 23. Brunnstrom S. Movement therapy in hemiplegia. New York: Harper & Row, 1970. 24. Hunter WC, Sneeden VD,Robertson TD, Snyder GAC. Thrombosis of the deep veins of the leg. Arch Intern Med 1941;68:1-17. 25. Husni EA, Ximenes JOC, Goyette EM. Elastic support of the lower limbs in hospital patients. lAMA 1970; 214:1456-62. 26. Gibbs NM. Venous thrombosis of the lower limbs with particular reference to bed rest. Br1Surg 1957;45:20936. 27. Wright HP, Osborn SB, Edmonds DG. Effect of postoperative bed rest and early ambulation on the rate of venous blood flow. Lancet 1951;1:22-5. 28. Consensus Conference: Prevention of venous thrombosis and pulmonary embolism. lAMA1986;256:7449. 29. Allan A, Williams JT, Bolton JP, LeQuesne LP. The use of graduated compression stockings in the prevention of postoperative deep vein thrombosis. Br 1Surg 1983; 70:172-4. 30. Myerowitz BR,Crook A. Elastic-stocking compression and venous blood-flow. Effect in the lower limb. Lancet 1960;1:122-4. 31. Paulsen PF, Creech 0 Jr, DeBakey ME. Observations on the venous circulation time in the lower extremities: effect of elevation and compression bandages. Surg Forum 1954;5:137-43. 32. Sigel B, Edelstein AL, Felix WR Jr, Memhart CR. Compression of the deep venous system of the lower leg
COMPRESSION STOCKlNGS IN HEMIPLEGIC PATIENTS
33.
34.
35.
36.
during inactive recumbency. Areh Surg 1973;106:3843. Lewis CE [r, Antoine J, Mueller C, et al. Elastic compression in the prevention of venous stasis. Alii ] Surg 1976;132:739-43. Sigel B, Edelstein AL, Savitch L, et al. Type of compression of reducing venous stasis. Areh Surg 1975; 110:171-5. Borow M, Goldstein H. Postoperative venous thrombosis . Evaluat ion of five methods of treatment. Alii ] Surg 1981;141:2 45-51. Caprini ]A, Chucker JL, Zuckerman L,et al. Thrombo-
sis prophylaxis using external compression. Surg Gyneeol Obslet 1983;156:599-604 . 37. Moneta GL, Bedford G, Beach K, Strandness DE. Duplex ultrasound assessment of venous diameters, peak velocities, and flow patterns. I Vase Surg 1988;8:28691. 38. Christopoulos DG, Nicolaides AN, Szendro G, Irvine AT, Bull M, Eastcott HHG . Air-plethysmography and the effect of elastic compression on venous hemodynamics of the leg. ] Vase Surg 1987;5:148-59 . 39. Mayberry JC, Moneta GL, DeFrang RD,Port er JM. The influence of elastic compression stockings on deep venous hemodynamics. ] Vase Surg 1991;13:91-100.
] STROKE CEREBROVASC DIS, VOL. 2, NO.4, 1992
201