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External Pneumatic Compression Devices
The Journal of Tissue Viability July 1991 Voll No 3
82
EXTERNAL PNEUMATIC COMPRESSION DEVICES S V S RITHALIA Department of Orthopaedic Mechanics, University of Salford, Salford, MS 4WT. INTRODUCTION The development of thromboembolic disease, often leading to pulmonary embolism (PE), is a major cause of morbidity and unexpected mortality in elderly patients during the post surgic~ period.1 For many years, external pneumatic compression (EPC) devices have been used successfully for the prevention of early post-operative deep vein thrombosis (DVT) and the treatment of chronic oedema. 2•3 The external pressure applied rhythmically on the chosen limb mimics the pumping action of the muscle, improving blood and lymphatic circulation and venous pulsatility 4.s, thereby encouraging fluid transfer from the interstitial spaces into the vascular system. Some investigators6·7 have also suggested that when the blood vessels and muscles are compressed, they release fibrinolysin which discourages thrombus formation.
results. However, it was not until the 1930s that the frrst objective responses to the application of alternate negative and positive pressure to ishremic limbs were demonstrated plethysmographically and by increased lower leg temperaturell. The next logical step was to develop vacuum-compression devices, which encourage peripheral tissue blood flow in the limbs under treatment 23 • This is a pursuit in which several electromechanical equipment manufacturers have been engaged in recent years 24• EQUIPMENT CLASSIFICATION There is extensive variation in devices currently available for pneumatic compression therapy 12.25. The equipment can be conveniently classified according to its mode of operation:
Recently, EPC therapy has been found effective for the enhancement of wound healing and recovery from lower limb ulcers, 8·9• It has also been prescribed for the conservative treatment of lympoedema 10 and peripheral vascular disease11 (PVD). Because of their widespread use both in hospital and at home in recent years, there has been a large increase in the number and variety of EPC devices12 available to the medical profession. HISTORICAL BACKGROUND The application of external compression in venous disorders of the lower limbs is not a new idea. Perhaps the earliest efforts were made in the 17th century with rigid lace-up stockings applied over the calf in an attemptto heal leg ulceration 13• Even elastic stockings in one form or another are thought to have been used for over 150 years. From an early part of the present century, with the development of pneumatic splints for the immobilisation of fractures, there has been a renewal of interest in compression therapy 14·15 .
In the 1950s, several investigators 16·17 suggested that the action of the calf muscle pump on the venous blood flow in the leg may be simulated by using rhythmical compression. Earlier devices mainly consisted of a modified pneumatic cuff, pressure gauge and reduction valve connected to compressed air supply. But the instruments of today have changed beyond recognition. They are self contained units employing an electromechanical air pump connected to specially designed airtight doublewalledgarments made of either polyvinyl chloride (PVC), clear plastic, or polyurethane impregnated fabric, with zip or velcro fasteners. It has been known for some time that the exposure of limbs to subatmospheric pressure increases their local content ofblood18. As early as 1835, Murrey19 noted an increase in lower leg blood flow following application of negative pressure. In 1908, Meyer and Schnieden20 proposed the use of alternating positive and negative pressure in the treatment of PVD. Using this regimen Sinkowitz and Gottlieb21 obtained excellent clinical
Fig 1 Intermittent pneumatic compression device (Flowton AC200/ 2; Huntleigh Technology pic HK) used on a patient: (a) pump, (b) garments.
These consist of a pneumatic pump connected to single-chamber garments or sleeves which exert uniform pressure on the limbs. The garments are inflated and deflated cyclically. There are several intermittent pneumatic compression (IPC) systems on the market 12. It appears that the important parameters to be considered, when choosing a device for a particular purpose, are the cycle time, rate of compression and intensity of pressure26. On the basis of these characteristics, the instruments can be categorised as variable cycle pumps and fixed cycle pumps 27• As the name·suggests, in fixed cycle pumps the inflation time and the deflation time is fixed, but the pressure in the garments can be varied. These devices are small, relatively cheap and simple to use, and therefore more suited to patients at home. Variable cycle pumps have separate controls for pressure and time settings. Their inflation and deflation times as well as pressures can be adjusted independently. They are extremely versatile for research and a variety of medical conditions. The air pressure is derived from a compressor leading to a distributor, whichisconnectedtomulti-chambergarmentsU. The distributor feeds compressed air at selected pressures to an individual chamber or cell of the garment. The chambers are inflated progressively, starting from the frrst distal chamber then the second, the third and so on. This results in a wave-like
The Journal of Tissue Viability July 1991 Vol1 No 3
83
During the compression phase, the capillaries and veins are largely emptied of their content of blood and the lymph is also drained. After the set time for the compression has elapsed, the pressure is gradually decreased and the suction phase begins. Depending on the parameters set, the vacuum or negative pressure phase is also developed gradually. The gradual transition from one pressure phase to the other avoids sudden supply and withdrawal of a quantity of blood with adverse effects on the central body circulation. In the negative pressure phase a passive hyperaemia is induced, which usually spreads from the proximal to the distal side of the limb.
Fig 2 Sequential pneumatic compression system (Centromed Major PP'IT; Centromed Ltd UK) in use: (a) pump, (b) garments.
the veins of the limbs under treatment. The instrument using garments divided into three compartments only are generally known as graded pneumatic compression (GPN) devices. These are not as effective as the truly sequential pneumatic compression (SPC) devices, which have sleeves consisting of six or more cells. From the literature review, it seems that grading or sequencing provides substantial improvement over uniform compression in reducing venous stasis 28 • Furthermore, it appears that the GPN and SPC remove fluid from the limbs more rapidly than does the IPC. The sequential compression has also proven to be the most effective technique to augment lymph flow29• Although SPC devices have many applications, these are expensive, bulky and complex machines.
Fig 3 Vacum-Compression therapy machine (Vasotrain 447; B V Enraf-Nonius Delft, Holland used on a patient: (a) compressor unit, (b) perspex cylinder, (c) control panel.·
In these devices, the mechanism exerts an alternating suction and pressure on the limb. The procedure involves enclosing the leg from the toes to the upper thigh level in a large cylinder made of clear plastic material. An inflatable rubber cuff around the extremity separates the inside from the outside air. The cylinder is connected to a powerful electromechanical pump which generates rhythmic alternating negative or positive pressure. The rate with which the suction or compression is built up can be regulated and the period during which the pressure should be maintained once the preset value has been reached can also be accurately adjusted 24•
There are some obvious limitations of vacuum compression therapy (VCT). It requires the active participation of the patient and the duration of treatment is frequently limited by patient discomfort 30 • The VCT devices are noisy, cumbersome and very expensive. Their use is restricted to specially trained hospital staff only. CLINICAL APPLICATIONS The maxim 'prevention is better than cure' is perhaps nowhere more appropriate than in the management of venous thrombosis. During the last two decades, intermittent compression of lower limbs has been used successfully in the prevention of early postoperative DVT. Many publications comparing low-dose subcutaneous heparin with EPC therapy and other prophylactic measures have appeared in the literature 31 -33 • In the majority of cases compression was used before, during, and after surgery 34•35 • But several investigators 31 .36 have shown thatECP is as effective when applied only intra-operatively as when used for longer periods. These investigations have led to a general recommendation and acceptance of compression therapy in prophylaxis against thromboembolic disease. In addition, recent reviews 32•37 of clinical trials have suggested that external compression is the most effective method for preventing DVT. It has been well established that EPC therapy of the limbs reduces both lymphoedema 38 and chronic oedema 39 • Being quantitatively more effective it enables the patient to use less compressive and more comfortable stockings. McMair and his associates 40 found that after the therapy stiff arms became lighter as well as mobile and tight skin became softer. Holt and Bennet:41 reported a large reduction in leg volume, up to one litre per leg, in a small group of six patients suffering with rheumatoid oedema. Several investigators 42•43 have demonstrated that the effectiveness of ECP can be significantly improved by the additional use of custom-fitted graduated elastic stockings or sleeves. Using this combination Leis et al 44 reported excellent results in 27 post-mastectomy patients. In a study of several surgical procedures, Pflug 4s found that compression reduced both oedema and pain in a number of wounds. This was later confirmed by Melrose and his colleagues 46 • A number of separate studies have been published, using IPC and SPC systems for the recovery of leg ulcers 47 , enhancement of wound healing 48 and improvementoflimbcirculation 49 • Other clinical applications includecorrection of fixed flexion deformity ofthekneeorelbow in patients with haemophilia so and reduction of spasm in cerebrovascular accident cases. The equipment has also been used to improve mobility in muscle dystrophy and multiple sclerosis patients. Most of the evidence that EPC devices provide any significant benefit to the disabled person is still anecdotal and subjective. The main group of patients who
The Journal of Tissue Viability July 1991 Vol1 No 3 can best benefit from alternating suction and compression machines are the elderly, diabetic or patients with multipathological conditions. Unfortunately VCT devices have been almost entirely remained unused in clinical practice.
CONCLUSIONS It seems highly likely that EPC therapy will assume greater prominence in the prevention of DVT and recovery from leg ulcers. It is also likely that self treatment oflower limb oedema, using IPC devices, will be used more at home. When it comes to selecting any equipment for self treatment or hospital environment the results of an independent evaluation offer the best opportunity for unbiased information, comparison and decision making. It is therefore critical that any electromechanical instruments used are correctly tested and validated before use in the clinical setting. A comparative study of different devices is helpful from all points of view. This should be supported by the Department of Health in their equipment evaluation programme. The author wishes to thank the staff of Hope Hospital and Mrs N Virtue for their assistance and Centromed for the photograph in Fig 2.
REFERENCES 1. Kakkar V V. Deep vein thrombosis: detection and prevention. Circulation 1975; 51: 8-19. 2. Hills N H, Pflug J J, Jeyasingh K. Prevention of deep vein thrombosis by intermittent pneumatic compression of calf. Br Med 1 1972; 1: 131-5. 3. Pflug J J. Intermittent compression in the management of swollen legs in general practice.Practitioner; 215: 69- 76. 4. Zeissler RH, Rose GB, Nelson PA. Postmastectomy lymphodema: late results of treatment in 385 patients. ArchPhys MedRehabil1972; 53: 160-6. 5. Roberts V C, Sabri S, Beely A H, Cotton LT. The effect of intermittently applied external pressure on the haemodynamics of the lower limb in man. Br 1 Surg 1972; 59: 223-6. 6. Allenby F, Boardman L, Pflug JJ, Calnan JS. Effects of external pneumatic intermittent compression or fibrinolysis inman. Lancet 1973; 2: 1412-1414. 7. Knight MTN, Dawson R. Effect of intermittent compression of the arm on deep venous thrombosis in the legs. Lancet 1976; 2:1265-7. 8. Morey KR, Watson Ah. Team approach to treatment of the post-traumatic hand. Phys Ther 1986; 66: 225-8. 9. Zelikovski A, Haddad M, Reiss R. The treatment of venous ulcers. In: Negus D, Jantet G, Editors. Phlebology 85. London: John Libbey Co Ltd, 1986: 655-8. 10. Compression for Lymphredema [Editorial]. Lancet 1986; 1:896. 11. Thomson A. Pneumotherapy for peripheral vascular disease and arterial disorders. Remed Therap 1980; 3: 6. 12. Rithalia SVS, Sayegh A, Edwards J. Consumer report on intermittent pneumatic compression devices. Clin Rehabi/1987; 1: 65-70. 13.Wiseman R. Several chirurgical treatses. London: Royston and Tooke, 1676. 14. Millar RE, Robertson G. A new pneumatic Splint pad. Lancet 1927; 2:508.
84
15. Curry GJ. A pneumatic leg splint: a preliminary report. lAMA 1944; 125: 966-8. 16. Allwood MJ. The effect of an increased local pressure gradient on blood flow in the footClin Sci 1957; 16: 231-9. 17. Loane RA. Effect of rhythmically inflating a pneumatic cuff at the ankle on blood flow in the foot. 1 Appl Physio/1959; 14: 411-3. 18. BrownE, Goei JS, Greenfield ADM, Plassaras GC. Circulatory responses to simulated gravitational shifts of blood in man induced by exposure of the body below the lilac crest to subatmospheric pressure. 1 Physiol 1966; 183: 607-27. 19. Murray J. On the local and general influence on the body of increased and diminished atmospheric pressure. Lancet 1835; 1: 909-11. 20. Meyer W, Schnieden V. Bier's hyperaemia treatment. Philadelphia: WB Saunder Co, 1908. 21. Sinkowitz SJ, Gottlieb L. Thrombo-angitis obliterans: the conservative treatment by Bier's hyperaemia suction apparatus. lAMA 1917; 68: 961-3. 22. Landis EM, Gibbon JH. The effect of alternate suction and pressure on blood flow to the lower extremities. 1 Clin Invest 1933; 925-61. 23. Krog JO. Vascular studies by means of external application of negative pressure. 1 Oslo City Hosp 1979; 29: 119-21. 24. Tielrooy WF. Vacuum-compression therapy. Delft: B V Enraf-Nonius, 1986. 25. Muhe E. Intermittent sequential high-pressure compression of the leg. Am 1 Surg 1984; 147: 781-5. 26. Sayegh A, Rithalia SVS, Andrews K. Performance characteristics of intermittent pneumatic compression systems. ClinRehabil1987; 1: 71-5. 27. Rithalia SVS. Intermittent pneumatic compression of the upper and lower limb. Care Sci Pract 1987; 5:21-5. 28.Zelikovski A, Manoach M, Giler S, Urea I. LymphaPress: a new pneumatic device for the treatment of lymphedema in the limb. 1 Cardiovasc Surg 1983; 24: 122-6. 29. Zelikovski A, Deutsch A, Reiss R. The sequential pneumatic compression device in surgery for lymphedema in the limb. 30. Rithalia SVS, Gonsalkorale M, Edwards J. Effects of vacuum compression therapy on blood flow in lower limbs. Int 1 Rehabil Res 1989; 12: 320-3. 31. Coe NP, Collins EC, Klein LA, Bettmann MA, Skillman JJ, Shapiro RM, et al. Prevention of deep vein thrombosis in urological patients: a controlled randomized trial of low-dose heparin and external pneumatic compression boots. Surgery 1978: 83: 230-4. 32. Borow M, Goldson H . Postoperative venous thrombosis: evaluation of five methods of treatment. Am 1 Surg 1981; 141: 245-251. 33. Moser G, Krahenbuhl B, Barroussel R, Bene JJ, Donath A. Mechanical versus pharmacological prevention of deep venous thrombosis. Surg Gynecol Obstet 1981; 152: 448-52. 34. Hull RD, Raskob GE, Gent M, McLoughlin D, Julian D, Smith FC, et al. Effectiveness of intermittent pneumatic
The Journal of Tissue Viability July 1991 Vol1 No 3 leg compression for preventing deep vein thrombosis after total hip replacement. lAMA 1990; 263: 2313-7 35. Lee BY, Madden JL, Trainor FS, Kavner D, Dratz HM, Ejercito E. Detection and prevention of deep vein thrombosis in the general surgical patient. In: Madden JL, Hume M, editors. Venous thromboembolism pre vention and treatment New York: Apple Century Crofts, 1976: 61-90. 36. Salzman EW, Ploetz J, Bettman M, Skillman J, Klein L. Intra-operative external pneumatic compression to afford long term prophylaxis against deep vein thrombosis in urologic patients. Surgery 1980: 87: 239-42. 37. Colditz GA, Tuden RL, Oster G. Rates of venous thrombosis after general surgery: combined results of randomised clinical trials. Lancet 1986; 2: 143-6. 38. Swedborg I. Volumetric estimation of the degree of lymphedema and its therapy by pneumatic compression. Scandl Rehabil Med 1977; 9: 131-5. 39. Pflug JJ, Davies DM. Chronic swelling of the leg and stasis ulcer. Br Med J 1985; 290: 1273-6. 40. McNair TJ, Martin U, Orr JD. Intermittent compression for lymphoedema of arm. Clin Oncol 1976; 2: 339-42. 41. Holt PJL, Bennet RM. Pneumatic stockings to treat 'Rheumatic Oedema'. Lancet 1972; 2:688-9. 42. Brush BE, Wylie JH, Beninson J. Some devices for the
85
management of lymphoedema of the extremities. Surg Clin North Am 1959; 39: 1493-8. 43. Nicolaides AN, Miles C, Hoare M, Jury P, Helmis E, Venniker R. Intermittent sequential pneumatic compression
of the legs and thromboembolism -deterrent stockings in the prevention ofpostoperative deep venous thrombosis. Surgery 1983; 94: 21-5. 44. Leis HP, Bowers WF, Dursi J. Postrnastectomy edema of arm. NY State J Med 1966; 6: 618-24. 45. Pflug JJ. Intermittent Compression: a new principle in treatrnentofwounds? Lancet 1974; 2: 355-6. 46. Melrose DG, Knight MTN, Simandl E. The stripping of varicose veins: a clinical trial of intermittent compression dressing. Br J Surg 1979; 66: 53-5. 47. McCulloch JM. Intermittent compression for the treatment of a chronic stasis ulceration. Phys Ther 1981; 61: 1452-3. 48. Redford JB. Experiences in the use of a pneumatic stump shrinker. Prosthet Orthot 1973; 12:1-7. 49. Al-See AK, Arfors KE, Bergqvist D, Dahlgren S. The hremodynamic and antithrombotic effects of intermittent pneumatic calf compression on femoral vein blood flow. Acta Chir Scand 1976; 142: 381-5. 50. Allen AL. Use of 'Flowtron' in haemophiliac patients and other with fixed flexion deformity problems. Physiotherapy 1988; 74: 581-2.
Diary Notes SALFORD HEALTH AUTHORITY INSTITIJTE OF REHABILITATION & GERONTOLOGY
PRESSURE SORES &LEG ULCERS
Professional Nurse WOUND CARE STUDY DAYS Autumn 1991 Schedule
A one-day seminar open to all members of the Health profession Topics will include: •
e e
e e e
e e e e
Aetiology Pathophysiology Biomechanical aspects of patient support Assessment of support surfaces Prevention of sores and ulcers Compression treatment of leg ulcers Nursing patients with pressure sores and leg ulcers Physiotherapists Contribution Pharmacists Contribution Clinical Audit
18109!91
• University of Belfast
07111!91
• Edinburgh
12112191
• Regent's Park, London
*COMMERCIAL EXHIBffiON *
FEE: £25- includes coffee,lunch and tea For further information and an application form please contact:
Mrs. Darrell Dillon, Administrator Inst of Rehab. & Gerontology Ladywell Hospital Eccles New Road Salford MS 2AA
Tel: 061 787 4034
Information on the above can be obtained from:
Michele Seagrove, Study Day I Coordinator/Secretary, Professional Nurse, Brook House, 2-16 Torrington Place, LONDON WClE 7LT
Tel: 071 636 4622
82
EXTERNAL PNEUMATIC COMPRESSION DEVICES S V S RITHALIA Department of Orthopaedic Mechanics, University of Salford, Salford, MS 4WT. INTRODUCTION The development of thromboembolic disease, often leading to pulmonary embolism (PE), is a major cause of morbidity and unexpected mortality in elderly patients during the post surgic~ period.1 For many years, external pneumatic compression (EPC) devices have been used successfully for the prevention of early post-operative deep vein thrombosis (DVT) and the treatment of chronic oedema. 2•3 The external pressure applied rhythmically on the chosen limb mimics the pumping action of the muscle, improving blood and lymphatic circulation and venous pulsatility 4.s, thereby encouraging fluid transfer from the interstitial spaces into the vascular system. Some investigators6·7 have also suggested that when the blood vessels and muscles are compressed, they release fibrinolysin which discourages thrombus formation.
results. However, it was not until the 1930s that the frrst objective responses to the application of alternate negative and positive pressure to ishremic limbs were demonstrated plethysmographically and by increased lower leg temperaturell. The next logical step was to develop vacuum-compression devices, which encourage peripheral tissue blood flow in the limbs under treatment 23 • This is a pursuit in which several electromechanical equipment manufacturers have been engaged in recent years 24• EQUIPMENT CLASSIFICATION There is extensive variation in devices currently available for pneumatic compression therapy 12.25. The equipment can be conveniently classified according to its mode of operation:
Recently, EPC therapy has been found effective for the enhancement of wound healing and recovery from lower limb ulcers, 8·9• It has also been prescribed for the conservative treatment of lympoedema 10 and peripheral vascular disease11 (PVD). Because of their widespread use both in hospital and at home in recent years, there has been a large increase in the number and variety of EPC devices12 available to the medical profession. HISTORICAL BACKGROUND The application of external compression in venous disorders of the lower limbs is not a new idea. Perhaps the earliest efforts were made in the 17th century with rigid lace-up stockings applied over the calf in an attemptto heal leg ulceration 13• Even elastic stockings in one form or another are thought to have been used for over 150 years. From an early part of the present century, with the development of pneumatic splints for the immobilisation of fractures, there has been a renewal of interest in compression therapy 14·15 .
In the 1950s, several investigators 16·17 suggested that the action of the calf muscle pump on the venous blood flow in the leg may be simulated by using rhythmical compression. Earlier devices mainly consisted of a modified pneumatic cuff, pressure gauge and reduction valve connected to compressed air supply. But the instruments of today have changed beyond recognition. They are self contained units employing an electromechanical air pump connected to specially designed airtight doublewalledgarments made of either polyvinyl chloride (PVC), clear plastic, or polyurethane impregnated fabric, with zip or velcro fasteners. It has been known for some time that the exposure of limbs to subatmospheric pressure increases their local content ofblood18. As early as 1835, Murrey19 noted an increase in lower leg blood flow following application of negative pressure. In 1908, Meyer and Schnieden20 proposed the use of alternating positive and negative pressure in the treatment of PVD. Using this regimen Sinkowitz and Gottlieb21 obtained excellent clinical
Fig 1 Intermittent pneumatic compression device (Flowton AC200/ 2; Huntleigh Technology pic HK) used on a patient: (a) pump, (b) garments.
These consist of a pneumatic pump connected to single-chamber garments or sleeves which exert uniform pressure on the limbs. The garments are inflated and deflated cyclically. There are several intermittent pneumatic compression (IPC) systems on the market 12. It appears that the important parameters to be considered, when choosing a device for a particular purpose, are the cycle time, rate of compression and intensity of pressure26. On the basis of these characteristics, the instruments can be categorised as variable cycle pumps and fixed cycle pumps 27• As the name·suggests, in fixed cycle pumps the inflation time and the deflation time is fixed, but the pressure in the garments can be varied. These devices are small, relatively cheap and simple to use, and therefore more suited to patients at home. Variable cycle pumps have separate controls for pressure and time settings. Their inflation and deflation times as well as pressures can be adjusted independently. They are extremely versatile for research and a variety of medical conditions. The air pressure is derived from a compressor leading to a distributor, whichisconnectedtomulti-chambergarmentsU. The distributor feeds compressed air at selected pressures to an individual chamber or cell of the garment. The chambers are inflated progressively, starting from the frrst distal chamber then the second, the third and so on. This results in a wave-like
The Journal of Tissue Viability July 1991 Vol1 No 3
83
During the compression phase, the capillaries and veins are largely emptied of their content of blood and the lymph is also drained. After the set time for the compression has elapsed, the pressure is gradually decreased and the suction phase begins. Depending on the parameters set, the vacuum or negative pressure phase is also developed gradually. The gradual transition from one pressure phase to the other avoids sudden supply and withdrawal of a quantity of blood with adverse effects on the central body circulation. In the negative pressure phase a passive hyperaemia is induced, which usually spreads from the proximal to the distal side of the limb.
Fig 2 Sequential pneumatic compression system (Centromed Major PP'IT; Centromed Ltd UK) in use: (a) pump, (b) garments.
the veins of the limbs under treatment. The instrument using garments divided into three compartments only are generally known as graded pneumatic compression (GPN) devices. These are not as effective as the truly sequential pneumatic compression (SPC) devices, which have sleeves consisting of six or more cells. From the literature review, it seems that grading or sequencing provides substantial improvement over uniform compression in reducing venous stasis 28 • Furthermore, it appears that the GPN and SPC remove fluid from the limbs more rapidly than does the IPC. The sequential compression has also proven to be the most effective technique to augment lymph flow29• Although SPC devices have many applications, these are expensive, bulky and complex machines.
Fig 3 Vacum-Compression therapy machine (Vasotrain 447; B V Enraf-Nonius Delft, Holland used on a patient: (a) compressor unit, (b) perspex cylinder, (c) control panel.·
In these devices, the mechanism exerts an alternating suction and pressure on the limb. The procedure involves enclosing the leg from the toes to the upper thigh level in a large cylinder made of clear plastic material. An inflatable rubber cuff around the extremity separates the inside from the outside air. The cylinder is connected to a powerful electromechanical pump which generates rhythmic alternating negative or positive pressure. The rate with which the suction or compression is built up can be regulated and the period during which the pressure should be maintained once the preset value has been reached can also be accurately adjusted 24•
There are some obvious limitations of vacuum compression therapy (VCT). It requires the active participation of the patient and the duration of treatment is frequently limited by patient discomfort 30 • The VCT devices are noisy, cumbersome and very expensive. Their use is restricted to specially trained hospital staff only. CLINICAL APPLICATIONS The maxim 'prevention is better than cure' is perhaps nowhere more appropriate than in the management of venous thrombosis. During the last two decades, intermittent compression of lower limbs has been used successfully in the prevention of early postoperative DVT. Many publications comparing low-dose subcutaneous heparin with EPC therapy and other prophylactic measures have appeared in the literature 31 -33 • In the majority of cases compression was used before, during, and after surgery 34•35 • But several investigators 31 .36 have shown thatECP is as effective when applied only intra-operatively as when used for longer periods. These investigations have led to a general recommendation and acceptance of compression therapy in prophylaxis against thromboembolic disease. In addition, recent reviews 32•37 of clinical trials have suggested that external compression is the most effective method for preventing DVT. It has been well established that EPC therapy of the limbs reduces both lymphoedema 38 and chronic oedema 39 • Being quantitatively more effective it enables the patient to use less compressive and more comfortable stockings. McMair and his associates 40 found that after the therapy stiff arms became lighter as well as mobile and tight skin became softer. Holt and Bennet:41 reported a large reduction in leg volume, up to one litre per leg, in a small group of six patients suffering with rheumatoid oedema. Several investigators 42•43 have demonstrated that the effectiveness of ECP can be significantly improved by the additional use of custom-fitted graduated elastic stockings or sleeves. Using this combination Leis et al 44 reported excellent results in 27 post-mastectomy patients. In a study of several surgical procedures, Pflug 4s found that compression reduced both oedema and pain in a number of wounds. This was later confirmed by Melrose and his colleagues 46 • A number of separate studies have been published, using IPC and SPC systems for the recovery of leg ulcers 47 , enhancement of wound healing 48 and improvementoflimbcirculation 49 • Other clinical applications includecorrection of fixed flexion deformity ofthekneeorelbow in patients with haemophilia so and reduction of spasm in cerebrovascular accident cases. The equipment has also been used to improve mobility in muscle dystrophy and multiple sclerosis patients. Most of the evidence that EPC devices provide any significant benefit to the disabled person is still anecdotal and subjective. The main group of patients who
The Journal of Tissue Viability July 1991 Vol1 No 3 can best benefit from alternating suction and compression machines are the elderly, diabetic or patients with multipathological conditions. Unfortunately VCT devices have been almost entirely remained unused in clinical practice.
CONCLUSIONS It seems highly likely that EPC therapy will assume greater prominence in the prevention of DVT and recovery from leg ulcers. It is also likely that self treatment oflower limb oedema, using IPC devices, will be used more at home. When it comes to selecting any equipment for self treatment or hospital environment the results of an independent evaluation offer the best opportunity for unbiased information, comparison and decision making. It is therefore critical that any electromechanical instruments used are correctly tested and validated before use in the clinical setting. A comparative study of different devices is helpful from all points of view. This should be supported by the Department of Health in their equipment evaluation programme. The author wishes to thank the staff of Hope Hospital and Mrs N Virtue for their assistance and Centromed for the photograph in Fig 2.
REFERENCES 1. Kakkar V V. Deep vein thrombosis: detection and prevention. Circulation 1975; 51: 8-19. 2. Hills N H, Pflug J J, Jeyasingh K. Prevention of deep vein thrombosis by intermittent pneumatic compression of calf. Br Med 1 1972; 1: 131-5. 3. Pflug J J. Intermittent compression in the management of swollen legs in general practice.Practitioner; 215: 69- 76. 4. Zeissler RH, Rose GB, Nelson PA. Postmastectomy lymphodema: late results of treatment in 385 patients. ArchPhys MedRehabil1972; 53: 160-6. 5. Roberts V C, Sabri S, Beely A H, Cotton LT. The effect of intermittently applied external pressure on the haemodynamics of the lower limb in man. Br 1 Surg 1972; 59: 223-6. 6. Allenby F, Boardman L, Pflug JJ, Calnan JS. Effects of external pneumatic intermittent compression or fibrinolysis inman. Lancet 1973; 2: 1412-1414. 7. Knight MTN, Dawson R. Effect of intermittent compression of the arm on deep venous thrombosis in the legs. Lancet 1976; 2:1265-7. 8. Morey KR, Watson Ah. Team approach to treatment of the post-traumatic hand. Phys Ther 1986; 66: 225-8. 9. Zelikovski A, Haddad M, Reiss R. The treatment of venous ulcers. In: Negus D, Jantet G, Editors. Phlebology 85. London: John Libbey Co Ltd, 1986: 655-8. 10. Compression for Lymphredema [Editorial]. Lancet 1986; 1:896. 11. Thomson A. Pneumotherapy for peripheral vascular disease and arterial disorders. Remed Therap 1980; 3: 6. 12. Rithalia SVS, Sayegh A, Edwards J. Consumer report on intermittent pneumatic compression devices. Clin Rehabi/1987; 1: 65-70. 13.Wiseman R. Several chirurgical treatses. London: Royston and Tooke, 1676. 14. Millar RE, Robertson G. A new pneumatic Splint pad. Lancet 1927; 2:508.
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15. Curry GJ. A pneumatic leg splint: a preliminary report. lAMA 1944; 125: 966-8. 16. Allwood MJ. The effect of an increased local pressure gradient on blood flow in the footClin Sci 1957; 16: 231-9. 17. Loane RA. Effect of rhythmically inflating a pneumatic cuff at the ankle on blood flow in the foot. 1 Appl Physio/1959; 14: 411-3. 18. BrownE, Goei JS, Greenfield ADM, Plassaras GC. Circulatory responses to simulated gravitational shifts of blood in man induced by exposure of the body below the lilac crest to subatmospheric pressure. 1 Physiol 1966; 183: 607-27. 19. Murray J. On the local and general influence on the body of increased and diminished atmospheric pressure. Lancet 1835; 1: 909-11. 20. Meyer W, Schnieden V. Bier's hyperaemia treatment. Philadelphia: WB Saunder Co, 1908. 21. Sinkowitz SJ, Gottlieb L. Thrombo-angitis obliterans: the conservative treatment by Bier's hyperaemia suction apparatus. lAMA 1917; 68: 961-3. 22. Landis EM, Gibbon JH. The effect of alternate suction and pressure on blood flow to the lower extremities. 1 Clin Invest 1933; 925-61. 23. Krog JO. Vascular studies by means of external application of negative pressure. 1 Oslo City Hosp 1979; 29: 119-21. 24. Tielrooy WF. Vacuum-compression therapy. Delft: B V Enraf-Nonius, 1986. 25. Muhe E. Intermittent sequential high-pressure compression of the leg. Am 1 Surg 1984; 147: 781-5. 26. Sayegh A, Rithalia SVS, Andrews K. Performance characteristics of intermittent pneumatic compression systems. ClinRehabil1987; 1: 71-5. 27. Rithalia SVS. Intermittent pneumatic compression of the upper and lower limb. Care Sci Pract 1987; 5:21-5. 28.Zelikovski A, Manoach M, Giler S, Urea I. LymphaPress: a new pneumatic device for the treatment of lymphedema in the limb. 1 Cardiovasc Surg 1983; 24: 122-6. 29. Zelikovski A, Deutsch A, Reiss R. The sequential pneumatic compression device in surgery for lymphedema in the limb. 30. Rithalia SVS, Gonsalkorale M, Edwards J. Effects of vacuum compression therapy on blood flow in lower limbs. Int 1 Rehabil Res 1989; 12: 320-3. 31. Coe NP, Collins EC, Klein LA, Bettmann MA, Skillman JJ, Shapiro RM, et al. Prevention of deep vein thrombosis in urological patients: a controlled randomized trial of low-dose heparin and external pneumatic compression boots. Surgery 1978: 83: 230-4. 32. Borow M, Goldson H . Postoperative venous thrombosis: evaluation of five methods of treatment. Am 1 Surg 1981; 141: 245-251. 33. Moser G, Krahenbuhl B, Barroussel R, Bene JJ, Donath A. Mechanical versus pharmacological prevention of deep venous thrombosis. Surg Gynecol Obstet 1981; 152: 448-52. 34. Hull RD, Raskob GE, Gent M, McLoughlin D, Julian D, Smith FC, et al. Effectiveness of intermittent pneumatic
The Journal of Tissue Viability July 1991 Vol1 No 3 leg compression for preventing deep vein thrombosis after total hip replacement. lAMA 1990; 263: 2313-7 35. Lee BY, Madden JL, Trainor FS, Kavner D, Dratz HM, Ejercito E. Detection and prevention of deep vein thrombosis in the general surgical patient. In: Madden JL, Hume M, editors. Venous thromboembolism pre vention and treatment New York: Apple Century Crofts, 1976: 61-90. 36. Salzman EW, Ploetz J, Bettman M, Skillman J, Klein L. Intra-operative external pneumatic compression to afford long term prophylaxis against deep vein thrombosis in urologic patients. Surgery 1980: 87: 239-42. 37. Colditz GA, Tuden RL, Oster G. Rates of venous thrombosis after general surgery: combined results of randomised clinical trials. Lancet 1986; 2: 143-6. 38. Swedborg I. Volumetric estimation of the degree of lymphedema and its therapy by pneumatic compression. Scandl Rehabil Med 1977; 9: 131-5. 39. Pflug JJ, Davies DM. Chronic swelling of the leg and stasis ulcer. Br Med J 1985; 290: 1273-6. 40. McNair TJ, Martin U, Orr JD. Intermittent compression for lymphoedema of arm. Clin Oncol 1976; 2: 339-42. 41. Holt PJL, Bennet RM. Pneumatic stockings to treat 'Rheumatic Oedema'. Lancet 1972; 2:688-9. 42. Brush BE, Wylie JH, Beninson J. Some devices for the
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management of lymphoedema of the extremities. Surg Clin North Am 1959; 39: 1493-8. 43. Nicolaides AN, Miles C, Hoare M, Jury P, Helmis E, Venniker R. Intermittent sequential pneumatic compression
of the legs and thromboembolism -deterrent stockings in the prevention ofpostoperative deep venous thrombosis. Surgery 1983; 94: 21-5. 44. Leis HP, Bowers WF, Dursi J. Postrnastectomy edema of arm. NY State J Med 1966; 6: 618-24. 45. Pflug JJ. Intermittent Compression: a new principle in treatrnentofwounds? Lancet 1974; 2: 355-6. 46. Melrose DG, Knight MTN, Simandl E. The stripping of varicose veins: a clinical trial of intermittent compression dressing. Br J Surg 1979; 66: 53-5. 47. McCulloch JM. Intermittent compression for the treatment of a chronic stasis ulceration. Phys Ther 1981; 61: 1452-3. 48. Redford JB. Experiences in the use of a pneumatic stump shrinker. Prosthet Orthot 1973; 12:1-7. 49. Al-See AK, Arfors KE, Bergqvist D, Dahlgren S. The hremodynamic and antithrombotic effects of intermittent pneumatic calf compression on femoral vein blood flow. Acta Chir Scand 1976; 142: 381-5. 50. Allen AL. Use of 'Flowtron' in haemophiliac patients and other with fixed flexion deformity problems. Physiotherapy 1988; 74: 581-2.
Diary Notes SALFORD HEALTH AUTHORITY INSTITIJTE OF REHABILITATION & GERONTOLOGY
PRESSURE SORES &LEG ULCERS
Professional Nurse WOUND CARE STUDY DAYS Autumn 1991 Schedule
A one-day seminar open to all members of the Health profession Topics will include: •
e e
e e e
e e e e
Aetiology Pathophysiology Biomechanical aspects of patient support Assessment of support surfaces Prevention of sores and ulcers Compression treatment of leg ulcers Nursing patients with pressure sores and leg ulcers Physiotherapists Contribution Pharmacists Contribution Clinical Audit
18109!91
• University of Belfast
07111!91
• Edinburgh
12112191
• Regent's Park, London
*COMMERCIAL EXHIBffiON *
FEE: £25- includes coffee,lunch and tea For further information and an application form please contact:
Mrs. Darrell Dillon, Administrator Inst of Rehab. & Gerontology Ladywell Hospital Eccles New Road Salford MS 2AA
Tel: 061 787 4034
Information on the above can be obtained from:
Michele Seagrove, Study Day I Coordinator/Secretary, Professional Nurse, Brook House, 2-16 Torrington Place, LONDON WClE 7LT
Tel: 071 636 4622