LID: compression therapy

Compression therapy indications

-UE or LE lymphedema

-venous edema

-post-surgical or post-traumatic edema

-shape residual limb post-amputation

Compression therapy contraindications

-acute untreated infections

-acute DVT

-untreated cardiac edema

-renal edema

-edema without dx

Compression therapy precautions

-cardiac edema

-arterial disease/wounds

-diabetes

-sensory deficits

-paralysis

-AMS

-sensitivity to compression products

-inability to perform home mgmt

For P's with ankle brachial index under ___, you don't want to apply any compression

<0.5 (only compress with medical supervision)

For patients with lymphedema and ABI>=0.8, what sub-bandage pressure should be used?

40-50

For patients with edema with or without ulceration, what sub-bandage pressure should be used?

30-40

For patients with venous insufficiency, what sub-bandage pressure should be used?

25-35

For patients with edema (non-ambulatory), dependent edema, and arterial disease with edema and ABI 0.7-0.5, what sub-bandage pressure should be used?

17-25

For patients with anti-embolism stockings and DVT prophylaxis, what sub-bandage pressure should be used?

16-18

What are some effects of compression?

-reduces arterial filtration

-reduces venous reflux

-enhances valve competence

-prevents re-accumulation of fluid

-increases the calf-muscle pump

-assists in breakdown of fibrosis

-provides support for tissues that have lost elasticity

Law of LaPlace

-pressure that is exerted on the tissues from bandaging = tension/radius (P=t/r)

-tension is delivered from bandage system; each bandage is applied with even tension

-radius: the smaller the radius of the limb, the greater the pressure exerted on the tissues

T/f the smaller the radius of the limb, the greater the pressure exerted on tissues

True

What is the effect of padding with compression?

-provides more even distribution of compression around the limb

-must be applied in areas of concavity, in areas to increase limb radius, and in areas of concern for the soft tissues

Resting pressure vs. working pressure

-resting: constant pressure externally applied by the bandage that may hinder refill of superficial vessels; highest values achieved with strong, very elastic bandages (ACE, 4-layer wrap)

-working: temporary pressure that is generated with muscle contraction that increases the efficiency of the muscle pump; highest values achieved with more rigid dressings (short stretch, Unna boot)

Short stretch vs. long stretch bandages

-short stretch: can be elongated 10-100% of resting length and has low resting pressure and high working pressure due to minimal elasticity; prevents circulatory compromise and tourniquet effect; minimal fluid re-accumulation, but loses pressure over time

-long stretch: can be elongated >100% resting length and has high resting pressure and low working pressure; highly elastic (ex. ACE), but may compromise circulation at rest and provides poor support when muscles are working; maintains pressure over time

Which type of bandage has high resting pressure and low working pressure and may compromise circulation at rest?

Long stretch

What are the determinants of compression (4)?

-elastic component of bandage

-degree of tension during application

-number of bandages applied

-condition of the bandages or garment(s)

What are the guidelines for application of short-stretch bandages?

-apply stockinette over moisturized skin

-pad skin and bony prominences

-apply multiple bandages of varying widths (6, 8, 10, 12 cm)

-overlap 50%, stretch 50%

Where should the highest pressure be located when bandaging an UE/LE?

-pressure should steadily decrease from distal to proximal

-highest pressure at the ankle/wrist

-assess pressure by feeling stiffness after application of each bandage

What is intermittent pneumatic compression (IPC)?

-repetitive, graded, sequential compression to assist in edema control

-multi-chambered, inflates sequentially from distal to proximal

-position patient with limb elevated and covered with stockinette

What is IPC dosage for venous edema?

-max pressure set to tolerance without exceeding DBP (generally 45-60 mmHg)

-rapid cycle time to inflate/deflate (30-45 sec)

-tx time 1 hour 1x/day

What is IPC dosage for lymphatic disease?

-max pressure set to tolerance around 40 mmHg

-tx time up to 1 hour 1x/day

IPC precautions/contraindications

-same contraindications as compression therapy: acute untreated infections and DVT, untreated cardiac edema, renal edema, edema without dx

-specific to lymphedema: swelling in abdomen or genitalia, primary lymphedema in 1+ area of body, BIL mastectomy

IPC disadvantages

-not all devices created equal

-doesn't remove all protein —> increased incidence of genital edema/proximal edema

-time: 1 hr/day

-may traumatize residual functioning lymph vessels

Which CPT code could you use for MLD and compression bandaging?

Manual therapy techniques: 97140

Which CPT code could you use for strength and endurance and ROM?

Therapeutic exercise: 97110

Which CPT code could you use for functional performance activities?

Therapeutic activity: 97530

Which conditions must be met for Medicare to cover CDT?

1.) physician documented dx of lymphedema (1° or 2°)

2.) P has documented signs and sx of lymphedema

3.) P or caregiver has ability to understand and comply with continuation of treatment regimen at home

How many compression garments will medicare cover?

-3 garments per body part for daytime every 6 months

-2 nighttime garments every 2 years

What are some goals you would want to consider when documenting CDT?

-independence in self-management including self-bandaging, self-MLD, exercise, and skin care

-volume reduction

-independence in donning/doffing compression garments

-demonstration of knowledge of how to care for garments and proper wear schedule

-understand of the etiology, risk, and risk reduction strategies for lymphedema

-reduce functional limitations

What is the difference in compression bandages vs. garments?

-the role of compression bandages is to achieve a stable edema reduction of the limb

-the role of compression garments is to maintain the treatment results

What are the different types of compression garments?

-circular knit garments

-flat knit garments

-non-custom garments

-custom garments

How are circular knit garments constructed and what are they best for?

-knitted on a cylinder

-lack a seam

-can be made in finer/thinner fabrics

-cosmetically more attractive

-highest degree of compression distally

Where do circular knit garments have the highest degree of compression?

-highest degree of compression distally

How are flat knit garments constructed and what are they best for?

-knit row by row

-can be produced in unlimited shapes and sizes in accordance with individual anatomic shape and deformity

-custom fit allows for a more precise level of compression

-ideal for stages 2 and 3- compression all the way around the extremity but not in a circular fashion where it could cut into the bend of the ankle

How are non-custom garments constructed and what are they best for?

-typically circular knit products

-standard sizing/measurements

-variety of lengths, sizes, compression classes, color choices

-less expensive, variable insurance reimbursement

-appropriate for limbs with “normal” contours

-better for less severe edema

How are custom garments constructed and what are they best for?

-flat knit —> best for moderate/severe edema

-circular knit —> not as strong as flat knit

-exact fit to the limb presentation

-appropriate choice for when the limb is of abnormal shape/size

-expensive, variable insurance reimbursement

What are the compression classes?

-TED hose: 12-20 mmHg

-compression class I: 20-30 mmHg

-compression class II: 30-40 mmHg

-compression class III: 40-50 mmHg

Indications for TED hose

-12-20 mmHg

-achiness, fatigue, mild edema in foot and/or ankle, mild varicosities, DVT prophylaxis, post-operative

Indications for compression class I

-20-30 mmHg

-family hx of varicose veins, mild lymphedema, prevention of venous ulcers, DVT prevention, mild venous insufficiency

Indications for compression class II

-30-40 mmHg

-CVI, moderate lymphedema, management of active venous ulcers, moderate and post-traumatic edema, varicosities during pregnancy, prevention of DVT/post-thrombotic syndrome

Indications for compression class III

-40-50 mmHg

-severe lymphedema, mgmt of active venous ulcers, severe CVI, severe tendency towards edema

What are considerations for nighttime compression garments?

-do not want high elasticity when not moving for an extended period

-often velcro garments

-sometimes pillowy garments sown in directional flow to move fluid out of extremity

Potential adverse effects of compression garments

-often occur d/t poor choice of therapeutic material, knit type, and compression level

-UE garments: arm sleeve without hand compression may lead to hand/finger edema, and rubbing of seams may cause pain or blisters/ulcers

-LE garments: open toe garments may exacerbate toe edema, however closed toe garments may not resolve this issue

What are some tactics for promoting adherence to compression therapy?

-education: adjusting to P's concerns

-strengthening of resources

-participative relationship between therapist and P

How long does the intensive phase (phase I) of CDT usually last?

At least 2 weeks, depending on severity