1. Pneumatic Devices and Compression Garments
Minerva Zaniebeth A. Gomez, PTRP
Faculty
Department of Physical Therapy
University of the Philippines -Manila

2. OBJECTIVES
Differentiate the various pneumatic devices and compression garments according to function/ purpose.
Identify the physiological effects of compression devices.

3. OBJECTIVES
Differentiate the indications, precautions and contraindication of the pneumatic devices and compression garments.

4. PHYSIOLOGICAL EFFECTS
Increased pressure in the interstitial fluids enhance venous and lymphatic return
Decreased capillary perfusion: decreased cellular activity and collagen synthesis

5. PNEUMATIC DEVICES
Apply external pressure to an extremity through an inflatable appliance (sleeve)
Come in a variety of sizes
Can be applied simultaneously with cold using a coolant (50°- 77° F) pumped through an inflatable sleeve.
The compression units are designed in such a way that it inflates either a single compartment, producing uniform circumferential pressure on the extremity or multiple compartments applying pressure in a sequential manner. Pressure is greater in distal compartments and lesser in proximal compartments.
Picture – these are what you call boots or sleeves attaches to the rubber hose of the machine. A stockinette is always used before applying the boots or sleeves.

6. Intermittent mechanical Compression
Jobst, Kendall, Chattanooga
Can be used in cases of chronic edema, lymphedema, stasis ulcer, traumatic edema, venous insufficiency, amputation
Generally set at an Inflation and deflation ratio of 3:1; to shape residual limb 4:1
1st picture – this is a Jobst compression device single chamber compression
2nd picture – still a jobst compression device but a sequential compression type
3rd picture – Kendall sequential compression device
4th picture – Chattanooga sequential compression device

7. 45-90 seconds on/ 15-30 seconds off, for edema reduction
Pressure should never exceed the patient’s diastolic BP
UE: Should not exceed mmHg
LE: Should not exceed mmHg
2nd bullet- to prevent occlusion of blood vessels; although some advise that pressure can fall between the DBP and SBP since the pressure is applied for only a short period of time.

8. Duration of treatment: 2-3 hours – lymphedema
2 hours – traumatic edema
2.5 hours (3X/week) - venous ulcers
4 hours (1-3 hour sessions) – residual limb reduction
These are only suggested dosages based on the Jobst compression device, so it may very depending on the machine you are using. A table on dosages for different conditions can be found in Hecox page 424

9. Pneumatic End-Diastolic Leg Compression
a.k.a. Intermittent Venous Occlusion
Used for chronic arterial occlusion
Delivers short pulses of mmHg every 20 seconds
INSERT PIC FROM BRADDOM page The mechanism is the same as the pumping action of the calf muscles on veins during walking. A cuff is strapped to the leg and connected to a compressor that rapidly inflates the cuff with air (80-100mmHg every 20 seconds). Improve blood flow and reduce dependent edema.

10. Remember! ALWAYS take the Patient’s BP before treatment
ALWAYS cover any open wounds with sterile gauze
ALWAYS use a stockinette
Amputated limbs: stockinette applied over elastic bandage
ALWAYS elevate the limb being treated for edema reduction

11. Sequential vs single chamber compression
What is the evidence?
Pilch, U., Wozniewski, M. and Szuba, A. (2009). Influence of compression cycle time and number of sleeve chambers on upper extremity lymphedema volume reduction during intermittent pneumatic compression.
Dittmar, A. and Krause D. (1990). A comparison of intermittent compression with single and multi-chamber systems in treatment of secondary arm lymphedema following mastectomy
Both studies concluded that both types can reduce edema and that there is no difference between the two with regards to lymphedema reduction. The study by Pilch found that a shorter cycle duration (1:1) with 3-chamber compression has better efficacy in edema reduction.

12. COMPRESSIVE GARMENTS
Rigid, semi-rigid or soft as condition requires.

13. Removable Rigid Dressings
Made of plaster of paris or fiberglass cast
Used after limb amputation to prevent post-operative edema
Can also reduce post-operative pain and enhance wound healing
1st bullet – suspended by a stockinet and supracondylar cuff adjusted by adding/ removing stockings

14. Semi-Rigid Dressing
Examples: Unna paste, air splint, controlled environment treatment (CET)
Used to control post-operative edema in limb amputations
Can also reduce post-operative pain and enhance wound healing
Removable rigid and semi-rigid dressing are both applied in the operating room

15. Unna Paste Has self-suspension
Can be changed easily an conforms to residual limb
Allows free motion in the proximal joints
Not as durable as the rigid dressing
Needs frequent changing than a rigid dressing
Last picture: unna boot – usually used for stasis ulcers

16. Air Splint
Has a plastic double wall bag pumped to a desired level of rigidity
Inexpensive and allows early ambulation
Plastic is hot and humid
INSERT PIC of air splint from O’Sullivan page 190
1st bullet – has a zippper which encases the entire extremity
3rd bullet – constant pressure does not conform to the limb and the plastic material can cause discomfort

17. Controlled environment treatment (CET)
Consists of a console and a polyvinyl bag
Has a sterilizing component
Allows active exercises of the involved limb and standing at bedside
Size hinders ambulation
Bag interferes with lying prone
CET – controlled environment treatment
2nd bullet – provided by the console

18. Soft Dressing Oldest method of limb amputation management
Relatively inexpensive
Poor control of edema
Requires skill in proper application
Can slip and form a tourniquet
May be indicated in local infection
2nd bullet – light weight and readily available
4th bullet – needs frequent reapplication, loosens through time, applied from distal to proximal with decreasing pressure as you go through.
6th bullet – but not the treatment of choice

19. They are different kinds of soft dressings, the most popular of which are the bandages. They can be made of different types of materials such as cotton. Cotton bandages are not as flexible as the elastic bandages. Bandages are considered as the least effective of shrinkage devices used in amputations. If poorly applied, can cause circumferential constriction with distal edema. 4-inch bandages are used for the legs and arms, 6-inch bandages are used for thighs and big arms. There are adhesive bandages as well especially used in sports injuries.
Elastic compression garments provides mmHg continuously depending on the brand.
Coban wraps can be applied to each finger to reduce edema of the hand

20. Elastic Bandages Least effective- - shaping residual limb
Can cause circumferential constriction
Provide mmHg continuous pressure depending on brand

21. Elastic Shrinkers Easy to apply Provide uniform compression
More expensive than bandages
Worn 24 hours/day except for bathing

22. Compressive Stockings
Chronic venous insufficiency
30-40 mmHg
Lymphedema
30-40 mmHg or
40-50 mmHg
40-50 mmHg or
50-60 mmHg – selective refractory patients
1st bullet – pressure gradient of 30-40mmHg
Both conditions usually use a knee-high length with a thigh-high stocking don over for lymphedema

23. Compressive Garments Burns At least 25 mmHg
Applied at least 23 hours/ day
Applied until the scar is mature
1st bullet – to exceed normal capillary pressure

24. Compression Gloves Made of nylon spandex
Used in hand edema such as in RA or hand injuries

25. INDICATIONS Post-amputation Chronic venous & arterial insufficiency
Lymphedema – i.e. post-mastectomy
Stasis ulcer
Burns RA
Sports injuries
Prevention of DVT
2. Circulatory impairments - such as arterial and venous insufficiency, prevention of DVT in bed ridden patients like in cases of SCI, Stroke, TBI
For chronic venous insufficiency and lymphedema – IPC, compressive garments in between pumping sessions and when volume stabilizes, compressive stockings
No.3 – compression therapy is the mainstay treatment. Non-elastic compression such as the Unna paste boot is usually used. Elastic compression may also be used, but the pressure provided may not be enough to heal stasis ulcers.
No. 5 – edema post-burn can be addressed with IPCs
No. 7 – compression can be applied by elastic wraps initially (i.e. ace bandages) and re-wrapping should be performed every 4 hours. IPCs with ice is can also be done.
No.8 – like in case of SCI, IPC and gradient elastic stockings can be used
IPCs can also be used in RSD

26. PRECAUTIONS
Impaired sensation
Uncontrolled HTN

27. CONTRAINDICATIONS Acute edema Acute inflammation Acute DVT
Acute pulmonary edema
Loss of sensation
Edema with cardiac or renal impairment
1. Acute edema in cases of acute traumatic injury, fracture

28. CONTRAINDICATIONS Cancer Impaired cognition Presence of infection
Obstructed lymph and vascular channels
Very old and very young patients

29. DOCUMENTATION Type of device Parameters used: settings, duration
Patient position
Goal of treatment (FOR format)
Response of patient

30. REFERENCES
Braddom, R. (2000). Physical Medicine and Rehabilitation. Singapore: Elsevier Science (Singapore) PTE LTD.
Delisa, J. (1993). Rehabilitation Medicine: Principles and Practice 2nd Ed. USA: JB Lippincott Company.

31. REFERENCES
Hecox, B., Mehreteab TA, Weisberg J. (1994). Physical Agents: A Comprehensive Text for Physical Therapists. USA: Appleton & Lange.

32. REFERENCES
O' Sullivan, S. (1988). Physical Rehabilitation: Assessment and Treatment 2nd Ed. USA: FA Davis Company.
O' Sullivan, S., & Siegelman, R. (2007). National Physical Therapy Examination. Review and Study Guide . USA: International Educational Resources Ltd.