COMPRESSION

Abdullah Akhtar
• “Compression is the application of a mechanical force
that increases external pressure on the body or a body
part.”
• Compression is generally used to improve fluid balance
and circulation or to modify scar tissue formation.
• Compression improves fluid balance by increasing the
hydrostatic pressure in the interstitial space so that it
becomes greater than that in the vessels.
• This can limit or reverse outflow of fluid from blood
vessels and lymphatic.
• Keeping fluid in the vessels or returning it to the vessels
allows it to circulate rather than to accumulate in the
periphery
• Compression can be
• Static
• exerting a constant force,
• Intermittent,
• with the force varying over time.
• With intermittent compression the pressure
may be applied to the entire limb all at one
time, or it maybe applied sequentially starting
distally and progressing proximally.
EFFECTS OF EXTERNAL COMPRESSION
• Improved venous and lymphatic circulation
• Limits the shape and size of tissue
• Increased tissue temperature
 IMPROVED VENOUS AND LYMPHATIC
CIRCULATION
• Both static and intermittent compression devices can increase
circulation since both can increase the hydrostatic pressure in
the interstitial space outside the blood and lymphatic vessels.
• An increase in extravascular pressure can limit the outflow of
fluid from the vessels into the interstitial space. where it
tends to pool. Keeping it in the circulatory system, where it
can circulate.
• Intermittent compression may improve circulation more
effectively than static compression because the varying
amount of pressure is thought to push fluids from the distal to
the proximal vessels.
• It is achieved when the venous and lymphatic vessels are
compressed, the fluid in them pushed proximally, and then,
when compression is reduced. the vessels can open and
refill with new fluid from the interstitial space. ready to be
pushed proximally at the next compression
• Sequential compression is thought to provide more
effective drainage than single-chamber, intermittent
compression because it can cause a wave of vessel
constriction moving in a proximal direction to ensure that
fluid is pushed along the vessels toward the heart rather
than in a distal direction.
• Improving circulation can benefit patients with edema, may
help to prevent the formation of venous thrombosis in
high-risk patients, may facilitate the healing of ulcers
caused by stasis.
 LIMITS THE SHAPE AND SIZE OF TISSUE
• Static compression garments or bandaging can provide a
form to limit the shape and size of new tissue formation.
• This type of compression acts as a second skin, which,
having an elastic compression element or being less
extensible than skin, limits the shape and size of the tissue.
• This effect of compression is exploited when compression
bandaging or garments are used
1. over residual limbs after amputation,
2. when compression garments are applied over burn-
damaged skin.
3. and when bandaging or garments are applied to
edematous limbs.
 INCREASED TISSUE TEMPERATURE
• Most compression devices, except those with built in
cooling mechanisms, increase superficial tissue
temperature because the device insulates the area to which
it is applied.
• A heavy compression stockings or an air-filled sleeve will
act as an insulator, preventing loss of body heat, thereby
increasing local superficial tissue temperature.
• Although the increase in temperature produced by
compression garments is not a direct effect of the
compressive forces, it has been proposed that the
increased activity of temperature-sensitive enzymes such as
collagenase, which breaks down collagen, produced by
these garments may be the mechanism by which they
control scar formation.
CLINICAL INDICATION FOR THE USE
OF EXTERNAL COMPRESSION
1. Edema
• Edema due to venous insufficiency
• Lymphedema
2. Deep venous thrombosis
3. Venous stasis ulcers
4. Residual limb shaping after amputation
5. Control of hypertrophic scarring
 EDEMA
• “Edema is the presence of abnormal amounts of fluid in the
extracellular tissue spaces of the body.”
• Normal equilibrium in the tissues is maintained by the balance
between the hydrostatic and osmotic pressure inside and outside the
blood vessels.
• THE HYDROSTATIC PRESSURE is determined by blood pressure and
effects of gravity.
• The higher hydrostatic pressure inside the vessels acts to push fluid
out of the vessels
• OSMOTIC PRESSURE is determined by the concentration of proteins
inside and outside the vessels
• Higher the osmotic pressure in side the vessels acts to keep the fluids
inside the vessels
• . Under normal circumstances, the hydrostatic pressure
pushing fluid out of the veins is slightly higher than the
osmotic pressure keeping fluid in, resulting in a slight loss
of fluid into the interstitial space.
• The fluid that is pushed out of the veins into the
interstitial space is then taken up by the lymphatic
capillaries, to be returned to the venous circulation at the
subclavian veins.
• This fluid, known as LYMPHATIC FLUID OR LYMPH, rich in
protein, water, and macrophages.
• Dysfunction in any of these mechanisms can result in
increased extravasation of fluid from the vessels into the
interstitial extravascuIar space or reduced flow of venous
blood or lymph back toward the heart, and thus the
formation of edema.
• The most common reasons patients develop edema are
1. venous insufficiency or
2. dysfunction of the lymphatic system.
• Edema may also occur after
• exercise,
• trauma,
• surgery or
• burns,
• or in conjunction with infection
• due to the increased vascular capillary permeability that occurs
with the acute inflammation associated with these events.
 EDEMA DUE TO VENOUS INSUFFICIENCY
• The peripheral vein‘s function is to carry whole deoxygenated blood
from the periphery back to the heart.
• W hen the calf muscles contract, they extra pressure on the outside of
the veins, which pushes the blood through the veins.
• Then, following the contraction the pressure falls allowing the veins to
refill.
• A healthy amount of skeletal muscle activity, such as occurs with
walking or running, or even with just rhythmic isometric muscle
contraction, provides a milking action to propel the blood in the veins
from the periphery back toward the heart.
• Valves within the vessels prevent backflow of the fluid.
• Lack of physical activity
• dysfunction of the venous valves due to degeneration,
• or mechanical obstruction of the veins by a tumor or inflammation
• can result in venous insufficiency and accumulation of fluid in the
periphery.
• The most common cause of venous insufficiency is
inflammation of the veins, known as phlebitis.
which causes thickening of the vessel walls and
damage to the valves.
• The increased amount of fluid that enters the
extravascular space and thus causes edema.
• If the limbs are then placed in a dependent
position, the edema will worsen because of
increased hydrostatic pressure due to gravity.
 LYMPHADEMA
• Fluid flows into the lymphatic system because
concentration of proteins inside the lymphatic is generally
higher than in the interstitial space.
• A s with the veins, flow along the lymphatic vessels in a
proximal direction depends on muscle activity.
• Such as walking or running, which compresses the vessels
and valves within the vessels and prevents backflow.
• Decreased levels of plasma proteins particularly albumin,
mechanical obstruction of the lymphatics abnormal
distribution of lymphatic vessels or lymph nodes, or
reduced activity can result in reduced lymphatic flow and
the formation of lymphedema
 Adverse consequences of edema
• Restrictions of range of motion ([Link]).
• Limitations of function,
• pain.
• chronic edema particularly lymphedema that has a high level of
protein, can also cause collagen to be laid down in the area, leading
to subcutaneous tissue fibrosis and hard induration of the skin.
• This may eventually cause disfiguring and disabling contractures and
deformities
• Chronic edema due to venous or lymphatic insufficiency also
increases the risk of infection.
• cellulitis,
• Ulceration
• Partial limb amputation
• Chronic venous insufficiency also often causes itching, dermatitis,
and brown pigmentation of the skin.
 How compression can reduce edema
• Compression is effective in controlling edema due
to venous insufficiency, lymphatic dysfunction, or
any of the other causes because it increases
extravascular hydrostatic pressure and circulation.
• If the patient has other underlying causes of
edema, such as infection, malnutrition inadequate
physical activity, or organ dysfunction, these must
also be addressed to achieve an optimal outcome
and to prevent recurrence of the edema.
• Compression of a limb with a static or intermittent device
increases the pressure surrounding the extremity to
counterbalance any increased osmotic or hydrostatic
pressure causing fluid to flow out of the vessels into the
extravascular space.
• If sufficient pressure is applied, the hydrostatic pressure
in the interstitial extravascular spaces becomes greater
than that in the veins and lymphatic vessels, reducing
outflow from the vessels and causing fluid in the
interstitial spaces to return to the vessels.
• Once fluid is in the vessels it can be circulated out of the
periphery, preventing or reversing edema formation.
• In addition, if an intermittent compression device is used,
it may also to move the fluid proximally through the
vessels.
 Prevention from DVT
• Deep venous thrombosis (DVTs) are blood clots in
the deep veins. They can occur when circulation is
poor or when there is inflammation of the veins.
• If circulation is poor, the blood may move slowly to
allow coagulation and the formation of a thrombus;
thus, an intervention that increases the circulatory
rate can reduce the risk of thrombus formation.
• DVT formation is most common in immobilized
patients, particularly after surgery or when
recovering from cardiac failure or stroke.
• The prophylactic application of external
compression devices to the foot and calf has been
shown to reduce the incidence of DVT formation
in patients who are hospitalized for a variety of
reasons including postoperative and post acute
stroke area and after spinal cord injury.
• External compression devices may also protect
against pulmonary embolism and reduce
mortality.
 Venous statsis Ulcers
• Venous stasis ulcers are areas of tissue breakdown and
necrosis that occur as the result of impaired venous circulation.
• Impaired venous circulation, which may be the result of lack of
muscle contraction, venous insufficiency, or mechanical
obstruction, can result in poor tissue oxygenation and
malnutrition, reduced local immunological responses, and an
accumulation of waste products, all of which can contribute to
cell death and tissue necrosis.
• Because compression can improve venous circulation and
because improving circulation may reduce these adverse effects,
diminish the risk of vascular ulcer formation, and facilitate
healing of previously formed ulcers.
• compression is the treatment of choice for venous stasis ulcers.
 Residual limb shaping after amputation
• Compression can be used for residual limb reduction and shaping
after amputation in order to help prepare the limb for prosthetic
fitting.
• Both static and intermittent compression are used for this
application,
• although intermittent compression has been shown to reduce the
residual limb in approximately half of the time required by other
techniques.
• For this type of application, when intermittent compression is used,
it is applied in conjunction with wrapping with an elastic bandage.
• Compression reduces residual limb size because it controls
postsurgical edema and prevents stretching of the soft tissues by
Excessive fluid accumulation.
 Control of Hypertrophic Scarring
• Hypertrophic scarring is a common complication of deep
burns and other extensive skin and soft tissue injuries.
• . Hypertrophic scars result in poor cosmesis and the
development of contractures that may restrict ROM and
function
• Although many approaches, including surgery
pharmaceuticals, passive stretch with positioning,
massage, and silicone gel are used to control hypertrophic
scar formation, compression is the most common.
• Compression may directly shape the scar tissue by acting
as a mold for the new tissue, decreasing local edema
formation, and facilitating improved collagen orientation
• When applying compression to control hypertrophic scar formation,
treatment is generally initiated once the new epithelium has formed,
and is then continued for I to 12 months or longer until the scar is no
longer growing and has reached maturity.
• Compression can be applied with elastic bandages, self-adherent
wraps, tubular elastic cotton supports, or elastic custom-fit
garments.
• With any of these approaches the compression pressure is
maintained at approximately 20 mm Hg to 30 mm Hg.
• It is recommended that the compression device are worn 24 hours
a day, except when bathing, in order to achieve maximum benefit.
• Common complications of this treatment include skin irritation
constriction of circulation, and restriction of joint motion.
 CONTRAINDICATION
• Heart failure or pulmonary edema
• Recent or acute DVT, thrombophlebitis, or pulmonary
embolism
• Obstructed lymphatic or venous return
• Severe peripheral arterial disease or ulcers due to
arterial insufficiency.
• Acute local skin infection
• Significant hypo-proteinemia -protein levels less than
2 g/dl
• Acute fracture or other trauma
 1. Heart failure or pulmonary edema

• compression pumps should not be used treat

edema of this etiology because the shift of
fluid from the peripheral to the central
circulation may increase the stress on the
failing organs
2. Recent or acute DVT, thrombophlebitis, or
pulmonary embolism
• Compression, particularly intermittent compression,
should not be used when the patient is known to have a
DVT, thrombophlebitis, or a pulmonary embolus because
thrombus may become dislodged or the embolus may
travel.
• This can occur because of direct mechanical agitation of
the clot by the compression or because of increased
circulation produced by compression.
• If a thrombus or embolus becomes dislodged, it may
travel in the bloodstream to a distant site and lodge in a
location where it impairs blood flow to an organ
sufficiently to cause organ damage, severe morbidity, or
even death.
 3. Obstructed lymphatic or venous return

• Compression is contraindicated when

lymphatic or venous return is totally
obstructed because in such cases increasing
the fluid load of the vessels cannot reduce the
edema until the obstruction has been
removed.
• May be due to tumor, thrombus, or any
damage to the lymph nodes
 4. Severe peripheral arterial disease or ulcers due to arterial
insufficiency.

• Compression should not be used in patients

with severe peripheral arterial disease or
where there are ulcers due to arterial
insufficiency because it aggravate these
conditions by closing down the diseased
arteries and further impairing circulation into
the area.
 5. Acute local skin infection

• Local skin infection is likely to be aggravated by

the application of compression because the
sleeves and skin coverings used increase the
moisture and temperature of the area,
encouraging e growth of microorganisms.
• If a chronic skin infection is present, single-use
sleeves that avoid cross-contamination from
one patient to another, or reinfection of the
same patient, may be used for the application
of intermittent compression.
6. Significant hypo-proteinemia -protein levels less than 2 g/dl

• Although peripheral edema is a common

symptom of sever hypoproteinemia, when the
serum protein level is less than 2 g/dL, the
resulting edema should not be treated with
compression because returning fluid to the
vessels will further lower the serum protein
concentration, potentially resulting in severe
and adverse consequences, including cardiac
and immunological dysfunction.
 7. Acute fracture or other trauma

• Intermittent compression is contraindicated

immediately after an acute trauma because
the motion caused by this intervention may
cause excessive motion at the site of trauma,
increasing bleeding, aggravating the acute
inflammation, or destabilizing an acute
fracture.
• Such effects can cause further damage at the
site of injury and impair healing
 PRECAUTIONS
• impaired sensation or mentation.
• Uncontrolled hypertension
• Cancer
• Stroke or significant vascular insufficiency
• Superficial peripheral nerves
 1. lmpaired sensation or mentation.

• Compression should be applied with caution

to patients with impaired sensation or
mentation because such patients may be
unable to recognize or communicate when
pressure is excessive or painful.
 2. Uncontrolled hypertension

• Compression should be applied with caution to

patients with uncontrolled hypertension
because compression can further elevate blood
pressure by increasing the vascular fluid load.
• Blood pressure should be monitored frequently
during treatment of these patients, and
treatment should be stopped if their blood
pressure increases above the safe level
determined by their physician.
 3. Cancer
• Compression can increase circulation which
may disturb or dislodge metastatic tissue,
promoting metastasis,
• or may improve tissue nutrition, promoting
tumor growth.
4. Stroke or significant vascular insufficiency

• Compression should be applied with caution

patients who have had a stroke or have signs
of significant cerebrovascular insufficiency,
such as a history of transient ischemic attacks.
• Caution is because the hemodynamic changes
caused by compression may alter circulation
to the brain.
 5. Superficial peripheral nerves
• When compression is applied over an area
where there is a superficial nerve, particularly
in a patient with significant weight loss, the
clinician should monitor closely for symptoms
of nerve compression, including changes in or
loss of sensation or strength
 APPLICATION TECHNIQUES
• COMPRESSION BANDAGING
• COMPRESSION GARMENTS
• INTERMITTENT PNEUMATIC COMPRESSION
PUMP
•
[Link] BANDAGES
Compression bandages are generally applied by wrapping them
around the limb in a figure 8 manner, starting distally and progressing
proximally.
• Circular or spiral wrapping are generally not recommended because
these configurations can result in the uneven application of pressure
and thus the uneven control of edema.
• The bandage should be applied tightly enough to apply moderate,
comfortable compression without impairing circulation.
• To avoid slipping of the compression bandage on the skin, cohesive
gauze or foam bandages are often applied under the compression
bandages directly against the patient's skin.
• Soft cotton may also be used as an under wrapping to absorb sweat
and to help distribute pressure more evenly. Compression bandages
with different amounts of elasticity and extensibility are available.
• More the extensibility of the bandage more will be the pressure
exerted by the it.
• UNNA’S BOOT
• A semi rigid bandage formed of zinc oxide-impregnated gauze can
also used.
• This type of bandage is applied to the lower extremity it is known
as an Unna's boot.
• This is typically used for the treatment of venous stasis ulcers.
• Zinc oxide impregnated gauze bandages become soft when wet
allow molding around the involved limb, and then harden as they
dry to form a semi-rigid boot.
• The boot is left on the patient for as long as 1 to 2 weeks, and then
removed and replaced.
• An Unna's boot provide a sustained compression force of 35mm Hg
to 40 mm Hg
• For all types of bandages, it must be applied so that compression,
be greatest distally, and gradually decrease proximally in order to
achieve an appropriate pressure gradient.
 Application Technique Compression
Bandages
1. Remove clothing and jewelry from the area to be treated.
2. Inspect the skin in the area.
3. Apply foam or cotton padding around anatomical indentations.
4. Dress and cover any wound according to the treatment regime
5. Apply a cohesive gauze, foam, or cotton under bandage to protect the skin
from the compression bandage and minimize slipping of the compression
bandage. Start distally and progress proximally.
6. Apply the compression bandage, starting distally and progressing proximally.
7. When applying a bandage to the lower extremity, first apply it around the
ankle to fix the bandage in place then wrap the foot and then bandage the
leg and thigh. Wrapping around the foot should be from medial to lateral.
8. When applying a bandage to the upper extremity, first apply it to the wrist
to fix it in place, then wrap the hand and bandage the forearm and arm.
bandage should be applied in a figure 8 manner.
 Advantages
1. Inexpensive.
2. Quick to apply once skill is mastered.
3. Readily available.
4. Extremity can be used during treatment.
5. Safe for acute conditions.
 Disadvantages
1. When used alone, does not reverse edema.
2. Effective only for controlling edema formation.
3. Requires moderate skill, flexibility, and level of
cognition to apply.
4. Compression not readily quantifiable or
replicable.
5. Bulky and unattractive.
6. Inelastic bandages are ineffective in controlling
edema in a flaccid limb.
 COMPRESSION GARMENTS
• Compression garments can provide various degrees of
compression and are available in custom-fit sizes for all
areas of the body and standard off-the-shelf sizes for the
limbs.
• They are generally made of washable Lycra spandex and
nylon and have moderate elasticity to provide a
combination of moderate resting and working pressure
• Off-the-shelf stockings providing a low compression force
of about 16 mm Hg to 18 mm Hg, known as anti
embolisms stockings, used to prevent DVT in bedridden
patient
 Application Techniques For Pressure
Garments
• Compression garments should be applied by gathering them
up, placing them on the distal area first, and then gradually
unfolding them proximally.
• Since the Compression garments need to be worn every day
throughout the day, except for bathing, to control edema, to
improve circulation ,or control scar formation.
• In general, with proper care, these garments last about 6
months, after which time they lost their elasticity and no
longer exert the appropriate amount of pressure.
• Garments also need to be re placed if there is a significant
change in limb sizes, as may occur with changes in edema or in
body weight.
 Advantages
1. Compression quantifiable( unlike bandaging).
2. Extremity can be used during treatment (unlike a
3. pump).
4. Less expensive than intermittent compression devices
for short-term use.
5. Thin and attractive ,available in various colors.
6. Safe for acute condition.
7. Can be used 24 hours/day, as for modification of scar
formation.
8. Preferred by patients to compression bandages.
 Disadvantages
1. When used alone, may not reverse edema that is
already present.
2. More expensive than most bandages.
3. Need to be fitted appropriately.
4. Require strength, flexibility and dexterity to put on.
5. Hot, particularly in warm weather
6. Expensive for long-term use, as they need to be
replaced at least every 6 months and the patient
requires at least two identical garments so that one is
available when the other is being laundered.
 INTEREMITTENT PNEUMATIC
COMPRESSION PUMP
• Intermittent pneumatic compression pumps are used to provide the force for
intermittent compression.
• The pump is attached, via a hose, to a chambered sleeve placed around the
involved limb.
• Intermittent compression is suitable for home use,
• the patient should always begin the course of therapy under medical
supervision.
• In general since a compression pump is used for only a number of hours each
day, the patient should use a static compression device between treatments,
in order to maintain the reversal of edema produced by the pump.
• The use of intermittent compression in conjunction with static compression
also generally improves the outcomes.
• For example, intermittent compression pumping twice a week in conjunction
with static compression with an Unna's boot was found to approximately
double the rate of venous ulcer healing compared with the use of Unna's boot
alone.
 Techniques of application IPCP
1. Determine that compression is not contraindicated for the
patient or the condition.
2. Remove jewelry and clothing from the treatment area and
inspect the skin. Cover any open wound with gauze or an
appropriat dressing.
3. Place the patient in a comfortable position, with affected
limb elevated. Limb elevation reduces pain and the edema
caused by venous insufficiency.
4. Measure and record the patient's blood pressure.
5. Measure and record the limb circumference at a number
of places with reference to bony landmarks.
6. Place a stocking over the area to be treated and
smooth out all the wrinkles.
7. Apply the sleeve From the unit
8. Attach the hose from the pneumatic compression
pump to the sleeve.
9. Set the appropriate compression parameters,
including
• inflation and deflation times,
• inflation pressure,
• and total treatment time.
• The inflation time is the period during which the
compression sleeve is being inflated or is at the maximal
inflation pressure.
• T he deflation time is the period during which the
compression sleeve is being deflated or is fully deflated.
• Inflation pressure is the maximum pressure during the
inflation time and is measured in (mm Hg). Most units can
deliver between mm Hg and 120 mm Hg of inflation
pressure.
• Total treatment time recommendations vary from 1 to 4
hours per treatment, with treatment frequency ranging
from 3 times per week to 4 times per day.
• For most applications treatments of 2 to 3 hours once or
twice a day are recommended.
10. Provide the patient with a means to call you during the treatment.
Measure and record the patient's blood pressure during the
treatment, and discontinue treatment if either the systolic or
diastolic pressure exceeds the limits set for the patient by the
physician.
11. When the treatment is complete, tum off the unit disconnect the
tubing, and remove the sleeve and stocking.
12. Re-measure and record limb volume in the same manner.
13. Re-inspect the patient's skin.
14. Re-measure and document the patient's blood pressure.
15. Apply a compression garment or bandage to maintain the
reduction in edema between treatments.
 Advantages
1. Actively moves fluids and therefore may be more
effective than static devices, particularly f or a flaccid
limb.
2. Compression quantifiable.
3. Can provide sequential compression.
4. Requires less finger and hand dexterity to apply than
compression bandages or garments.
5. Can be used to reverse as well as control edema.
6. Use can be supervised in a patient who is non
compliant with static compression.
 Disadvantages
1. Used only for limited times during the day, and therefore not
appropriate for modification of scar formation.
2. Generally requires a static compression device to be used
between treatments.
3. Expensive to purchase unit or to pay for regular treatments
in a clinic.
4. Requires moderate comfort using machinery to apply.
5. Requires electricity.
6. Extremity cannot be used during treatment.
7. Patient cannot move about during treatment.
8. Pumping motion of device may aggravate an acute condition.
 Recommended Parameters for the
Application of Intermittent Compression

Problem Inflation/deflation Inflation pressure Treatment time

time(seconds) (mmHg) (hours)
edema, DVT 80-100/25-35 30-60 UE 2-3
Prevention, venous 40-80 LE
stasis ulcers
Residual limb 40-60/10-15 30-60 UE 2-3
reduction 40-80 LE