Intermittent Intermittent CompressionCompressionDevicesDevices

Jennifer Doherty-Restrepo, ATC, LAT

Entry-Level Athletic Training Education Program

PET 4995: Therapeutic Modalities

DefinitionsDefinitions

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

The Lymphatic SystemThe 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

The Lymphatic SystemThe Lymphatic System

Closed vascular system

Parallels arterial system

Lymphatic capillaries made of single layered endothelial cells

The Lymphatic SystemThe Lymphatic System

Lymphatic capillaries are surrounded by interstitial fluid

Terminal lymphatics provide entry way into lymphatic system for excess interstitial fluid and plasma proteins

The Lymphatic SystemThe 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

The Lymphatic SystemThe 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

The Lymphatic SystemThe 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

Injury Edema: Injury Edema: Pitting EdemaPitting 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

Injury Edema: Injury Edema: Pitting EdemaPitting 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

Injury Edema: Injury Edema: LymphedemaLymphedema

Accumulation of edema causing overdistention of lymph capillariesEntry 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

Negative Effects of EdemaNegative 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

Treatment of EdemaTreatment 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

Treatment of Edema: Treatment of Edema: ElevationElevation

Gravity used to assist lymph flow

The higher the elevation, the greater the effect on the lymph flow

Treatment of Edema: Treatment of Edema: CompressionCompression

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

Treatment of Edema: Treatment of Edema: WeightWeight-Bearing ExerciseBearing 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 locallyFunctions to relax smooth muscle and

stimulate blood flow in the veins

Treatment of Edema: Treatment of Edema: CryotherapyCryotherapy

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

Intermittent Compression Intermittent Compression Treatment ParametersTreatment Parameters

Inflation Pressure On/Off Time Sequence Total Treatment Time

Inflation PressureInflation Pressure

Loosely correlated with BP

Most treatment protocols utilize a pressure approximating diastolic BP

Inflation PressureInflation Pressure

Arterial capillary pressures ~ 30 mmHg

Any pressure that exceeds this should encourage Edema absorption,

and Lymph flow

Inflation PressureInflation 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

On/Off Time SequenceOn/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

Total Treatment TimeTotal 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

Equipment Setup and InstructionsEquipment 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

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

Cold and Compression Cold and Compression CombinationCombination

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

Compression and Electrical Compression and Electrical Stimulating CurrentsStimulating Currents

Combination of compression and e-stim induced muscle pumping is effective in treating edema

Facilitates reabsorption of injury byproducts by lymphatic system

Sequential Compression PumpsSequential Compression Pumps

Sequentially inflate compression sleeves with multiple compartments

Massage effect Applies pressure

from distal to proximal

Gradual decrease in pressure gradient

Sequential Compression PumpsSequential 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

Sequential Compression PumpsSequential 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

IndicationsIndications

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

ContraindicationsContraindications

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