Intermittent Pneumatic Compression Dosage for Adults and Children with Lymphedema: A Systematic Review

Jane Phillips, Susan J. Gordon, LYMPHATIC RESEARCH AND BIOLOGY, 2018

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Intermittent Pneumatic Compression Dosage for Adults and Children with Lymphedema: A Systematic Review

Jane Phillips, Susan J. Gordon, LYMPHATIC RESEARCH AND BIOLOGY, 2018

Background: Pneumatic compression has been used for more than 40 years in the management of lymphedema (LE). Modes of application have evolved with little consensus regarding optimal treatment parameters or dosage. The aim of this systematic review was to report the evidence for dosage of intermittent pneumatic compression (IPC) for people with LE and, particularly, that for upper versus lower limbs or child versus adult dosage.

Methods: Medline, Embase, CINAHL, PubMed, and Scopus were searched with terms, including LE and IPC devices, with no restriction on time. Other materials searched included reference lists of included articles. Study Selections: Systematic review registration: PROSPERO ID: CRD42017054338. Studies were assessed according to PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines and were excluded if they were not in English, not human, had physiological outcomes, or studied IPC in combination with other therapies. Quality appraisal, using the McMaster University Critical Review Tool, was undertaken by two researchers with differences resolved by a third. One hundred twenty-two full-text studies were screened for eligibility.

Results: Sixteen met inclusion criteria for final analysis. Of these, four were reported separately due to concurrent use of compression garments during the study period. One randomized controlled trial met the requirements for a level II (National Health and Medical Research Council) rating; the remainder were level III2 and below. Devices applying compression via multichamber sleeves were more commonly used in the past 20 years, with a trend toward lower pressures and shorter treatment times compared with earlier studies. Little evidence exists for application of specific dosage of IPC for children or a particular limb. New devices utilizing lower pressures support home use and self-management of LE.

Conclusion: Low-level evidence of moderate quality shows significant outcomes achieved with dosage times of 45–60 minutes, applying pressures between 30 and 60mmHg in sequential IPC programs. Methodological limitations in most studies suggest caution in drawing conclusions.

Main findings

  • Overall, the quality was poor for IPC-alone studies, with a mean score of 8 out of 15 (12 studies: range 4–11).
  • Device variety resulted in differences between studies based on cycle time, sleeve configuration, number of cells per sleeve, and pattern of pressure application, quite apart from dosage. Modes of compression described included the following: a. Single-cell applying intermittent pressure30,32; b. multiple cells applying sequential pressure by filling cells one after the other until all were full, then deflating pressure in one cell, then the next cell inflated before the previous one deflated, peristaltically moving up the limb before beginning distally again.
  • While many studies compared one IPC with another, one investigated pressure time cycles with either single-cell or three-cell garments with the same device. Having found significant reductions in all groups, it was concluded that all types of timing and sleeve configuration are effective. Another study reports that a 10-chamber IPC delivered a significantly greater reduction in percentage volume than either single-cell or three-cell devices. However, both studies had limitations that restrain conclusions.
  • Further investigation of the interaction of IPC with the skin, where up take of fluid is initiated in the initial lymphatics and where pressure is widely distributed around a limb in comparison with the focused manual application of pressure, may elucidate the optimal mode of application for fluid flow. Furthermore, it has been suggested that NIRFLI to outline fluid pathways before compression therapy might enable individually tailored IPC application.
  • There is limited low- to moderate-quality evidence for the application of 45–60 minutes of 30–60mmHg using multicell, sequential IPC programs for the management of UL LE.
  • Whether the addition of the root of the limb and adjacent truncal area to the limb is necessary requires further investigation.38 Further research on IPC outcomes, utilizing the same application frequency, duration, and pressures, will provide comparative data to build a basis for optimal dosage.
  • The inclusion of outcomes beyond limb volume and dimension, such as tonometry and bioimpedance, will allow control for potential confounding factors such as tissue hardness (stage of LE) and broaden understanding of the impact of IPC on skin condition and fluid flow, relevant to LE management. The inclusion of patient-centered outcomes such as burden of treatment versus symptom management will add optimal IPC use to dosage outcomes.
  • Based on the findings of the latter studies, a reduction of 11.8% would be deemed clinically significant, produced with a dosage of 60mmHg over 2 hours.26 As the highest level of evidence available, this dosage is worthy of note. The next greatest reduction of 6.8%–9.6% limb volume was produced with half the IPC duration and a mean pressure of 37.7mmHg.35 Both studies applied IPC daily, although device characteristics differ; further investigation of daily versus less frequent application may further elucidate optimal IPC frequency.