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Physical Methods for Prophylaxis

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 9. Evaluating Physical Methods for the Prevention of DVT

Author Year

Country

Research Design

PEDro Score

Sample Size

 

 

Methods

 

 

 

Outcomes

Becker et al., (1987)

USA

RCT

PEDro=6

N=15

 

Population: Age range=17-75yr; Gender: males=11, females=3; Severity of injury: complete/incomplete.

Chronicity: Acute.

Intervention: Rotating treatment tables.

Outcome Measures: Impedance blood plethysmography.

1.     4/5 control individuals and only 1/10 treated individuals developed positive fibrinogen leg scans.
Matsumoto et al., (2015)

Japan

Observational

N=29

Population: Mean Age: 63.2yr; Gender: males=25, females=4; Injury etiology: High fall (n=11, 38%), Fall at ground level (n=8, 28%), Motor Vehicle Accident (n=4, 14%), Sports (n=3, 10%), Low fall (n=2, 7%), Stairs (n=1, 3%); Severity of Injury: American Spinal Injury Association Impairment Scale (AIS) A=9, AIS B=2, AIS C=8, AIS D=10; Level of Injury: C3-4=11, C5-8=8, T1-12=6, L1-4=4.

Chronicity:<24 hr post SCI.

Intervention: All individuals were monitored for the development of deep venous thrombosis (DVT) after surgery and after they had received Intermittent pneumatic compression (IPC) with a calf pump and elastic stockings. The pump was attached throughout the day for at least 2wk after surgery and the elastic stockings were utilised after a median of 3 days post-surgery. Assessments were conducted 1, 3, 7, 14, and 28 days post-surgery.

Outcome Measures: Development of deep venous thrombosis (DVT), D-Dimer levels.

1.      DVT developed in 12 individuals (41.4%), all of which were located distal to the popliteal vein.

2.      The median length of time from surgery to detection of DVT was 7.5 days.

3.      Seven of the 12 individuals (58.3%) with DVT were classified as AIS A, one classified as AIS B (8.3%), three classified as AIS C (25.0%), and one classified as AIS D (8.3%).

4.      Mean D-Dimer level in individuals who developed DVT was 14.6+13.5ug-ml but this was not significantly different compared to individuals who did not developed DVT (p>0.05) at all assessment time-points except for 7 days after surgery (p=0.028).

5.      Cutoff D-Dimer levels according to the receiver operator characteristic curve did not differ significantly between individuals who developed DVT and those who did not except for 3 days after surgery (p=0.0287).

Chung et al., (2011)

Korea

Pre-Post

N=37

Population: Mean age=53 yr; Gender: Males=26, females=11; Level of injury: cervical-lumbar; Severity of injury: American Spinal Injury Association Impairment Scale (AIS) A-D.

Chronicity: All individuals were studied beginning within 1 week of injury.

Intervention: Only routine mechanical prophylaxis was administered to all individuals in the form of gradient elastic stockings (GES), external sequential pneumatic compression, and early ambulation.

Outcome Measures: Incidence of deep vein thrombosis (DVT) or pulmonary embolism (PE).

Method of Diagnosis: Doppler ultrasonography.

Timing of DVT onset: Routine checks for DVT were performed every 2 weeks beginning usually within 1 week of injury. 27% of individuals developed DVT within 7 days after injury, 8% developed DVT within 2-3 weeks after injury, and 8% developed DVT>1 month after injury.

Incidence of DVT:

1.     43% of individuals developed DVT.

2.     2 individuals (5%) developed a PE.

3.     Incidence of DVT in individuals in the present study was higher when compared to studies using pharmacological forms of prophylaxis.

Maxwell et al., (2002)

USA

Case Series

N=111

 

Population: Mean age=37.5 yr; Gender: males=81%, females=19%; Level of injury: not specified; Severity of injury: paraplegia=41.4%, tetraplegia=58.6%.

Chronicity: Individuals were hospitalized and monitored for an average of 23 ± 20 days following injury.

Intervention: Retrospective review of individuals using sequential compression devices alone or in combination with 5000 IU low dose unfractionated heparin (LDUH) subcutaneously every 12 hr or low molecular unfractionated heparin (LMWH) (Enoxaparin) 30 mg subcutaneously every 12 hr.

Outcome Measures: Incidence of deep vein thrombosis (DVT) or pulmonary embolism (PE).

Method of Diagnosis: Venous duplex ultrasonography.

Timing of DVT onset: Screening for DVT was performed on average 2.3 times during each admission. No other information was provided.

Incidence of DVT:

1.     The overall incidence rate for DVT and PE in SCI individuals was 9.0% and 1.8%, respectively, which was not significantly different.

2.     The incidence of DVT and PE in individuals using compression only was 7.1% and 2.4%, respectively.

Winemiller et al., (1999)

USA

Case Series

N=285

Population: Mean age=26 yr (VTE), mean age=25 yr (no VTE); Gender: males=88% (VTE), males=72% (no VTE); Level of injury: cervical-lumbar/sacral; Severity of injury: Frankel scores: A-B.

Chronicity: All individuals were studied for the initial 6 week duration following injury.

Intervention: Retrospective review of individuals who were administered antithrombotic prophylaxis (sequential compression devices (SCD)/gradient elastic stockings (GES)) or unfractionated heparin (UFH)) for 42 days-6 weeks after injury.

Outcome Measures: Incidence of deep vein thrombosis (DVT) or pulmonary embolism (PE).

Method of Diagnosis: Fibrinogen scans, impedance plethysmography, Doppler studies, venograms, and ventilation-perfusion scanning.

Timing of DVT onset: DVT/PE first detected at a median of 14.5 days after injury. 63% of initial DVT/PE events occurred within the first 3 weeks.

Incidence of DVT:

1.     Overall Incidence of DVT/PE was 19.6%.

2.     Multivariate analysis showed that SCD and GES were associated with a reduced risk of venous thromboembolism.

3.     The risk reduction for heparin compared to SCD/GES was not significant (p=0.06 (95% CI, 0.05-1.08) for the first 14 days, p=0.13 for anytime); SCD/GES and heparin seemed to each be effective.

4.     SCD/GES should be continued after 2 weeks post injury.

CHRONIC
 

Nash et al., (2000)

USA

RCT

PEDro=8

N=20

Population: Mean age=27.9yr; Gender: males=20; Level of injury: tetraplegic=20; Chronicity: 2mo-17yr post SCI.

Intervention: Individuals were randomized into one of two groups: 1) Slow sequential pneumatic compression devices (SCD)-15sec compression, 45sec relaxation at 35 mmHg (ankle), 30 mmHg (calf) or 20 mmHh (thigh); or 2) intermittent pulsatile compression (IPC-2sec compression, 18sec relaxation at 160mmHg.

Outcome Measures: Venous flow/min (VFM); average venous velocity (AVV); maximum venous velocity (MVV); for bilateral popliteal and femoral veins at rest (baseline) and during compression.

1.      Popliteal vein: no differences between devices.

2.      Femoral vein: increase in VFM and MVV during IPC versus SCD (p<0.05).

3.      Rest versus compression: VFM, AVV and MVV, all increased during compression (p<0.001).

 

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 I125 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.

More recent studies studying the prophylaxis using isolated compression devices is a study by (Do et al. 2013). The authors used only compression for VTE prophylaxis on 185 SCI patients. DVT was detected in 51 of the 185 patients and non-fatal PE was conformed in 13 patients in the first three months. No patients displayed thrombosis more than three months after SCI. Another similar study utilized only pneumatic compression and elastic stockings, but no anticoagulation. Patients were on compression devices all day except when they were out of bed. Elastic stockings were on most of the time except when bathing. DVT was diagnosed in 12 patients out of the 29 enrolled (Matsumoto et al. 2015). The Consortium for Spinal Cord Injury (2008) clinical practise guidelines, supports the application of mechanical compression devices early after injury since it is the period of highest VTE incidence (p. 38).

Conclusion

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

There is level 1b evidence (from one 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.