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Physical Methods for Prophylaxis

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Although pharmacological measures have been generally the preferred treatment for venous thromboembolism prophylaxis post SCI, mechanical means of limiting venous stasis can also serve to reduce the incidence of DVT post SCI. Mechanical treatments are designed to limit stasis and increase fibrinolytic activity in the paralyzed lower extremities. However, it should be noted that use of these devices should be accompanied by twice daily inspection for skin discolouration or breakdown, and broken blood vessels. Pneumatic compression devices are not suitable for patients with severe arterial insufficiency.

Table: Evaluating Physical Methods for the Prevention of DVT

Discussion

A variety of mechanical measures to reduce the incidence of DVT post SCI have been studied. Becker et al.  (1987)studied whether rotating treatment tables would prevent the development and progression of DVT in acute SCI patients. The authors noted that rotating treatment tables had been used up to that time in acute SCI patients to maintain spinal cord alignment while facilitating nursing care, allowing even distribution of ventilation and preventing pressure sores. It was hypothesized that because these appliances rotated continuously, they might serve to inhibit thrombosis formation by reducing venous stasis. This randomized trial involved 15 patients with acute SCIs. Four of the five control (nonrotated) patients developed distal and proximal thrombi, assessed by I-125 fibrinogen scanning and impedance plethysmography while only one of the ten treated (rotated) SCI patients developed both distal and proximal venous thrombi (p=0.007).

Winemiller et al. (1999)examined the medical charts of 285 SCI patients and found that sequential pneumatic compression devices (SCD) or gradient elastic stockings (GES) were associated with a reduced risk of venous thromboembolism. Multivariate analysis also suggested a decreased risk of venous thromboembolism in SCI patients treated with heparin in the first 14 days or anytime within 42 days. Although this risk reduction was approximately twice that of SCD/GES it was not statistically significant. A pre-post study by Chung et al. (2011) also examined the use of GES, external SCD and early ambulation. To better examine the effectiveness of mechanical compression, individuals were not offered pharmacological prophylaxis which may have contributed to the high DVT incidence (43%) across the study.

According to the Consortium for Spinal Cord Injury (2008) clinical practise guidelines, it is recommended that health care providers should “apply mechanical compression devices early after injury” (p. 38).

Conclusion

There is level 4 evidence (from 1 pre-post study and 1 case series; Chung et al. 2011; Winemiller et al. 1999) that sequential pneumatic compression devices (SCD) or gradient elastic stockings (GES) were associated with a reduced risk of venous thromboembolism post SCI.

There is level 1b evidence (from 1 RCT; Becker et al. 1987) that rotating treatment tables reduce the incidence of venous thrombi in acute SCI patients.

  • Sequential pneumatic compression devices and gradient elastic stockings may reduce the incidence of venous thromboembolism post SCI.
  • Rotating treatment tables may reduce the incidence of venous thromboembolism post SCI.