Mechanical Modalities

Intermittent Compression / Sequential Compression Devices (SCD’s)

• Consists of mechanical pump and sleeve

• Mimics the gastric/soleus muscle pump

• Single vs multi-chamber sleeves

Indications for use - Intermittent Compression / Sequential Compression Devices (SCD’s)

• Circulatory conditions

• Edema control

• DVT prevention

• PAD

• Venous ulcers

• Venous insufficiency

• Lymphedema

Contraindications- Intermittent Compression / Sequential Compression Devices (SCD’s)

• Acute pulmonary edema

• CHF - Congestive Heart Failure

• Recent or acute DVT

• Acute fracture

• Uncontrolled HTN

Precautions- Intermittent Compression / Sequential Compression Devices (SCD’s)

• Recent skin graft

• Acute skin infection

• Impaired sensation

• Impaired cognition

Edema

• Edema = extra fluid in interstitial space

• Causes:

  • Systemic pathology- cardiac, pulmonary, renal

  • Acute inflammatory process

• Consequences:

  • Pain

  • Dec ROM

  • Dec function

  • Infection risk

Intermittent Pneumatic Compression (IPC) - Effect on Edema

• Compression leads to elevated interstitial pressure which helps fluid flow into venous circulation and lymph system

  • Lymph system helps remove waste products

• Compression results in forward propulsion of blood. The accelerated flow (increased peak flow velocity) prevents venous statis and can aid in the clearance of valve sinuses

Intermittent Pneumatic Compression (IPC) for deep vein thrombosis (DVT) prevention

• If nothing is done for prophylaxis, 80% of pts post ortho sx will develop a DVT

• Alternative and adjunct to pharmacological (Sadaghianloo, 2016)

• Doesn’t increase bleeding risk like anticoagulants do

• In conjunction with early mobilization

Intermittent Pneumatic Compression (IPC) for Peripheral Artery Disease

• Circulatory condition- narrowed arteries reduce blood flow to legs and feet

• Improves claudication distance to a similar extent as exercise but is not a replacement (Sheldon, 2013)

• Blood returns proximally and the pressure gradient created allows for increased arterial blood flow distally

• Sig improvements found in toe blood pressure, popliteal flow, dec pain, improved QOL, and improved 6mWT (Bellew)

• Improved walking capacity, pressure indices, and QOL in pts with arterial claudication (Delis, 2005)

  • Effective, complication-free, and well-favored

  • Benefits maintained at 1 year after cessation of tx

Venous Stasis Ulcers

• Arises from impaired blood flow in the leg veins

• Oxygen poor blood doesn’t make it back to heart

• Causes: immobility, obesity, pregnancy, calf muscle pump dysfunction, genetics

Intermittent Pneumatic Compression (IPC) for Venous Statis Ulcers

• Mechanism of action of IPC: decreases venous pressure and interstitial edema

  • Collapses superficial venous system and forces blood into the deep system

  • Prevents fluid and protein leakage from the skin capillaries

• Can greatly accelerate wound closure

• Rapid inflation pattern (2-3x/min) is superior to slower.

• 2020 SR-

• IPC was more efficacious than standard compression bandages and it improved healing rates and reduced pain (Bliven, 2020)

Intermittent Pneumatic Compression (IPC) for Lymphedema

• Decreases capillary filtration which decreases lymph formation

• Must have adequate pressure

• Inconclusive evidence on effectiveness (Tran, 2017)

  • Decongestive therapy + IPC compared to decongestive therapy alone

    • No sig diff in volume reduction

    • No sig diff in pain and paresthesia

  • No sig diff in QOL

  • No adverse events with IPC

  • IPC, irrespective of chambers or cycle time, could be used in combination with other treatment program for up to two months

  • IPC that mimics MLD process is more effective in reducing leg volume compared to traditional sequential IPC (Dunn, 2022)

How do I know it’s working? What do I measure?

• Limb circumference

• Blood flow tests

• Time to wound healing (or wound depth, width, measures)

• Presence/absence of DVT

• Edema reduction (pitting test)

Monitor for: During/immediately after tx, monitor for:

• Swelling in other areas

• Joint stiffness 2t immobility

• SOB 2t fluid overload

• Numbness or tingling in extremity from compression or positioning

Steps - Intermittent Pneumatic Compression (IPC)

1. Check contraindications and precautions

2. Remove jewelry and clothing

3. Ask pt to use bathroom

4. Measure vitals

5. Take pre-measures- circumference, edema, etc

6. Position pt- optimize for gravity flow of fluid and pt comfort/support

7. Cover any open wounds, if present and clean/dry the limb

8. Select smallest sleeve that provides adequate coverage. Place on pt.

9. Select parameters if manufacturer’s settings allow

   1. Inflation pressure- about 30 mmHg which is arterial capillary pressure

   2. On/off time

   3. Tx duration: 45 min to 1 hr typical

   4. Recommendations vary. Pt comfort is important.

10. Give pt call bell

11. Begin treatment/press start. Monitor vitals during.

12. At end of treatment, turn off and assess skin

13. Consider applying compression garment or wrap post treatment in order to maintain gains

Documentation

• Vitals

• Circumferential measurements

• Area treated

• Wound description, if present

• Pt position

• Inflation pressure

• On/off time

• Total tx time

• Pt response

What is Traction ?

• Application of stretching forces on the cervical or lumbar spine

• Often accomplished through specialized tables but may also be achieved with body weight, weight, or pulleys

• Distraction-manipulation and positional distraction are different than traditional lumbar or cervical traction

Indications for traction

• Radicular symptoms

• Relief of pain with manual traction

  • Reduced pressure on nerves and discs

  • Degenerative disc disease

  • Herniated discs

• Complementary treatment

Theorized Effects of Traction -

• Cervical

  • Fluid exchange and nutrient transport within disc

  • Increased intervertebral foramina dimensions

  • Possibly enhanced by combined flexion

  • Possible immediate reduction in disc herniation extent

  • Mixed evidence on c-spine muscle activity

• Lumbar

  • Fluid exchange and nutrient transport within disc

  • Reduced intradiscal pressures

  • Reduced expansion of herniated disc material

• Limited sustained duration of effects; short lasting

Theorized Effects of Traction - Cervical

• Fluid exchange and nutrient transport within disc

• Increased intervertebral foramina dimensions

• Possibly enhanced by combined flexion

• Possible immediate reduction in disc herniation extent

• Mixed evidence on c-spine muscle activity

Theorized Effects of Traction - Lumbar

Fluid exchange and nutrient transport within disc

Reduced intradiscal pressures

Reduced expansion of herniated disc material

What Does the Evidence Say? - Traction

• Lack of strong evidence

• Mechanical traction is not effective for acute or chronic nonspecific LBP

• “These findings indicate that traction, either alone or in combination with other treatments, has little or no impact on pain intensity, functional status, global improvement and return to work among people with LBP. There is only limited-quality evidence from studies with small sample sizes and moderate to high risk of bias…These conclusions are applicable to both manual and mechanical traction.” (Wegner, 2013)

• Traction and manual therapy led to pain reduction but manual therapy was more effective in long term functional outcomes and QOL. Manual therapy is prioritized for long term recovery (Rashid 2020)

• Exercise therapy was more effective than lumbar traction in long term function and reducing disability (Hassan, 2021)

  • Manual traction did provide some immediate pain relief which allowed pts to participate more actively in exercise therapy

Contraindications - Traction

• Unstable spine conditions

• Acute inflammatory conditions

• Acute c-spine trauma

• Hx of steroid use

• Recent whiplash

• Localized instability/hypermobility

• Connective tissue disease

• Surgical stabilization or decompression

• Rheumatologic disorders

• Spine implants

• Joint hypermobility

• Pregnancy

• Ankylosing spondylitis

• Spinal tumor or infection

• Osteoporosis/osteopenia

• Recent c spine discectomy

Precautions - Traction

Claustrophobia

COPD

Pt distress

Steps- Cervical

1. Attach cervical harness to motor if it’s not already set up

2. Put slack in the cable and attach to mobile portion

3. Remove slack

4. Position pt in supine with head on the flat area.

5. Adjust lower body pt position for comfort.

   1. Pillows under knees, towels under arms

6. Adjust height of wedge to ensure contact along inferior cranium.

   1. If too high, slippage could occur.

7. Adjust width of wedge to provide secure fit with compression

8. Adjust harness angle- if flexion is desired

9. Give pt safety switch

10. Select duration and dosage

11. Begin traction and observe pt response and tolerance

12. Remove upon completion of session. Give pt a few min rest in supine

Steps- Lumbar

1. Remove outer/excess clothing layers

2. Position pt on table- prone vs supine

3. Position pelvic and thoracic harnesses

4. Ensure targeted spinal area or lumbosacral junction is at table separation

5. Position LE’s for comfort (hooklying or 90/90 on stool)

6. If two pelvic straps are present, upper goes superior to iliac crest. Lower is between iliac crest and greater trochanter

7. Thoracic harness goes inferior to widest part of rib cage

8. Tighten straps

9. Attach cable to pelvic harness

10. Remove slack

11. Release table lock

12. Give pt safety/call button

13. Input parameters and begin traction

14. Monitor pt and ensure harnesses don’t slip and that tension is appropriate

15. Stop treatment when finished and lock table before pt gets up

16. Allow pt a few minutes rest before getting up

What to Watch For

• Should be a comfortable experience

• Should not have symptoms worsening

• Should not have referred symptoms