A Systematic Review of Pneumatic Compression Systems: Identifying Safe Cuff Pressures and Inflation Durations for Clinical and Biomedical Applications

doi:10.21203/rs.3.rs-7624337/v1

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Systematic Review

A Systematic Review of Pneumatic Compression Systems: Identifying Safe Cuff Pressures and Inflation Durations for Clinical and Biomedical Applications

https://doi.org/10.21203/rs.3.rs-7624337/v1

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Pneumatic compression devices are used across therapeutic, diagnostic, surgical, and sports medicine applications to improve vascular function, lymphatic drainage, and circulation. However, there is a lack of consolidated guidance on safe and effective cuff pressures and inflation durations, which are critical parameters for both clinical safety and device design. This systematic review aims to identify and summarize the pressure levels and inflation cycles employed in peer-reviewed studies, providing valuable insights for biomedical engineers and clinicians developing and using such technologies. A comprehensive literature search was conducted in PubMed, Scopus, and ScienceDirect for articles published between 2000 and March 2025. Of 12,375 articles identified, 120 studies met the eligibility criteria. Data were extracted on device type, anatomical location, pressure settings, inflation/deflation durations, and clinical context. Findings revealed a wide variability in pressure settings across applications, with therapeutic devices employing pressures ranging from 30 to 120 mmHg, while surgical tourniquets exceeded 200 mmHg. Inflation durations ranged from a few seconds to 45 minutes depending on the context. Despite widespread use, few studies referenced standardized safety thresholds. This review highlights the urgent need for harmonized pressure-duration guidelines and serves as a reference point for engineers designing next-generation pneumatic compression systems.

Biotechnology and Bioengineering

Biomedical Engineering

Physiology

Biophysics

Physical Medicine & Rehab

Vascular Medicine

Cardiac & Cardiovascular Systems

Medical Physics

Mechanical Engineering

Pneumatic compression

cuff pressure

inflation time

intermittent compression

peripheral arterial disease

diabetic foot ulcer

biomedical engineering

Pneumatic compression devices are widely employed in modern medicine for the management of various vascular and lymphatic conditions. These devices apply cyclic or sustained pressure to limbs via inflatable cuffs to enhance venous return [1], reduce edema [2], promote arterial perfusion [3], and prevent thromboembolic events [4, 5]. Clinical applications include the treatment of chronic conditions such as diabetic foot ulcer (DFU) [6] and peripheral arterial disease (PAD) [7, 8], as well as postoperative recovery, diagnostic imaging [9], and athletic performance enhancement [10, 11].

Despite their widespread use, there is no standardized consensus on the optimal cuff pressure and inflation duration for different clinical indications. Excessive pressure or prolonged inflation may cause tissue damage or impede perfusion, while insufficient pressure may render treatment ineffective. These parameters are also critical for biomedical engineers developing safe, effective, and user-friendly wearable or hospital-based compression systems.

The purpose of this systematic review is to evaluate the range of pressures and inflation durations reported in the literature, identify safety thresholds, and provide guidance for future device development. To our knowledge, this is the first comprehensive review to aggregate these technical parameters across multiple disciplines and device types.

This systematic review was conducted in accordance with the PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) [12] guidelines.

Eligibility criteria

This study included human studies which employed pneumatic compression systems across various clinical applications, including therapeutic, diagnostic, surgical, and sports medicine contexts. However, a few exclusion criteria were set to identify the peer-reviewed journal articles for this systematic review. The exclusion criteria are as follows:

Duplicate results

Conferences / posters

Review papers and editorials

Book chapters

Indexes and contents

Animal studies

Non-cuff-based pressure measurement studies

Studies not mentioning “pressure” or “inflation duration”

Non-English studies

Abstracts without full texts

Information about databases

The search was conducted in three online databases, namely, PubMed, Science Direct, and Scopus, to include studies on pneumatic compression systems which were published before 18 March 2025. The search included studies published since 2000.Additionally, we identified a few studies by checking the references of the included articles.

Search strategy

A comprehensive search strategy was developed using keywords for four applications – therapeutic, diagnostic, surgical, and sports medicine – of pneumatic compression systems. The list of keywords prepared for each application are discussed in the supplementary materials. These keywords were combined using the Boolean operators “AND” and OR” during the database search. All three authors (AC, DK, and JC) were involved in selecting relevant keywords for this systematic review.

Selection process

All retrieved articles were imported into a reference management software (EndNote), and duplicates were removed. Two authors (AC and DK) independently screened the titles and abstracts of the articles for relevance. Discrepancies were resolved through discussion between the two authors or by consulting the third author (JC). Full texts of potentially eligible studies were retrieved and assessed for their final inclusion.

Data collection process

A standardized data extraction form was developed and piloted. The following data were extracted from each included study:

Author(s), year of publication, and study design
Device type and manufacturer
Device placement (e.g., calf, thigh, buttocks)
Cuff pressure (mmHg), inflation/deflation time, and cycle duration
Indication and patient population
Primary outcomes and study conclusions

Data extraction was performed independently by two authors (AC and DK).

Study outcomes

The primary outcomes were the reported cuff pressure and inflation time applied during the use of pneumatic compression devices across clinical application areas: therapeutic, diagnostic, surgical, and sports medicine. Secondary outcomes included the device location, clinical application (indication), and therapy type.

Statistical analysis

Descriptive statistics were used to summarize study characteristics and device parameters. Continuous variables were reported as medians with interquartile ranges, where appropriate. Data visualizations including box plots were generated using MATLAB to display trends in pressure and time across studies.

Study selection process

Our systematic search identified 12,370 articles across ScienceDirect, Scopus, and PubMed. An additional 5 records were obtained through other sources, resulting in a total of 12,375 articles. After removing duplicates, 10,089 unique records remained and were screened by title and abstract. Of these, 313 full-text articles were assessed for eligibility, and 120 studies were included in the systematic review [1, 2, 4, 5, 7–11, 13–123]. The study selection process is detailed in Fig. 1.

Included studies characteristics:

Of the 120 studies included in this review, the majority were categorized as therapeutic studies (72/120, or 60%). Surgical studies accounted for 34% (41/120), while diagnostic and sports medicine studies contributed 2% and 4%, respectively. All of the included studies were published between 2000 and 2025.

Table 1 summarizes the studies that employed pneumatic compression systems for therapeutic purposes. Three major types of devices were identified: intermittent pneumatic compression (IPC) device, sequential compression device (SCD), and external enhanced counter pulsation (EECP) system. IPC devices were used in 58% of the studies, while SCDs were used in 19%. EECP therapy was administered in 11 studies. Notably, five studies incorporated both IPC and SCD devices. These compression therapies were applied to manage a range of clinical conditions, including venous thromboembolism (VTE), deep vein thrombosis (DVT), lymphedema, and PAD. The diversity of applications highlights the clinical versatility of pneumatic compression systems. Table 2 presents the characteristics of surgical studies, all of which employed pneumatic tourniquet systems. These studies detail device settings, such as fixed or patient-specific cuff pressure based on systolic blood pressure (SBP) / limb occlusion pressure (LOP) and total tourniquet time, typically used in procedures such as orthopedic or vascular surgeries.

Table 3 details the diagnostic applications of pneumatic compression. Both studies in the diagnostic category employed compression cuffs to enhance vascular diagnostics: one study used pneumatic compression during magnetic resonance imaging (MRI) to assess venous outflow, while the other used it to measure arterial compliance via pulse waveform response. Device placement varied from the calf to the thigh, and pressures used were 50 mmHg and 200 mmHg. These studies demonstrated the feasibility of integrating pneumatic compression to facilitate physiological assessments and improve image clarity, despite their limited sample size. Table 4 presents five studies under the sports medicine category, all of which investigated blood flow restriction (BFR) therapy during exercise or recovery protocols. Devices were applied to the upper or lower limbs, and cuff pressures were commonly reported as a percentage of SBP or LOP, typically ranging from 40% to 130%. The duration of compression during exercise sessions ranged from 5 to 45 minutes. These studies aimed to improve muscular strength, vascular adaptation, or post-exercise recovery, highlighting the emerging interest in pneumatic compression for performance enhancement and rehabilitation in athletic and clinical populations. Only a few studies reported complications associated with pneumatic compression for therapeutic, surgical, and sports medicine purposes. The most common complications were pain, discomfort, wound, and skin damage along with a few other minor complications.

Table 1
Summary of included therapeutic studies using pneumatic compression systems
Study	Device type	Device location	Cuff pressure (mm Hg)	Inflation time (s)	Deflation time (s)	Complications	Therapeutic action
Ahlbom et al. (2016)	EECP	Calves, thighs	300	diastolic phase	systolic phase	None	Angina management
Alvarez et al. (2015)	SC	Foot, ankle, calf	120	4	16	Mild to moderate pain	PAD, CLI
Amanatullah et al. (2020)	IPC	Calf	45–73	1–11	60	None	VTE
Asano et al. (2001)	IPC	Foot	130	1	19	None	Pulmonary embolism
Beck et al. (2015)	EECP	Calves, lower thighs, upper thighs / buttocks	300	diastolic phase	systolic phase	None	left ventricular dysfunction
Ben-Galim et al. (2004)	IPC	Calf	50	6	-	None	DVT
Berliner et al. (2018)	SC, IPC	Calf	45–52	6–8	36–56	None	VTE
Berni et al. (2009)	SC	Calf, foot	120	3	-	Mild calf pain	IC
Braithwaite et al. (2016)	IPC	Foot	130	6	54	DVT, dorsal foot ulcer, skin maceration	VTE
Breu et al. (2014)	SC, IPC	Calf, foot	120	17	2–3	Adverse events	PAD
Broderick et al. (2010)	IPC	Foot	200	3	-	None	Venous blood flow enhancement
Casey et al. (2008)	EECP	Calves, lower thigh, upper thigh	300	diastolic phase	systolic phase	None	Angina pectoris with CAD
Chang et al. (2012)	SC, IPC	Foot, calf	120–140	1	15	None	PAD
Charles et al. (2013)	IPC	Foot	282	2	-	None	VTE
Choi et al. (2014)	SC	Leg	40–45	11–12	28	None	Thromboprophylaxis
Cohen et al. (2007)	EECP	Calves, thighs	80–300	diastolic phase	systolic phase	None	Acute coronary syndrome & CS
Colwell et al. (2010)	IPC	Calf	50	8	36–56	None	DVT prophylaxis
de Haro et al. (2010)	IPC	Calf	65	3	-	None	PAD
Delis et al. (2000) [44]	IPC	Foot, calf	60–140	4	-	None	Venous emptying optimization
Delis et al. (2000) [48]	IPC	Foot, calf	120	4	16	None	Peripheral vascular disease, IC
Delis et al. (2000) [49]	IPC	Foot	180	3	17	None	Peripheral vascular disease, IC
Delis et al. (2000) [50]	IPC	Foot, calf	120–180	3	-	None	DVT prophylaxis
Delis et al. (2001)	IPC	Calf / thigh	120	4	16	None	Arterial flow enhancement
Delis et al. (2002)	IPC	Foot, calf	120	4	16	None	Skin blood perfusion enhancement
Delis et al. (2005)	IPC	Foot, calf	120	4	16	None	Arterial claudication enhancement
Dietz et al. (2020)	SC	Calf	50	8	36–56	DVT, PE, blister formation	DVT
Eisele et al. (2007)	SC	Calf	45–52	6	-	None	DVT prophylaxis
Feldman et al. (2006)	EECP	Calves, thighs, buttocks	300	diastolic phase	systolic phase	None	CHF
Ginzburg et al. (2003)	IPC	Calf	40	12	48	DVT, PE, bleeding	DVT prophylaxis
Grieveson et al. (2003)	IPC	Lower limbs	30–40	15	10	Pain, discomfort, edema, cramp	Venous insufficiency
Iwama et al. (2000)	IPC	Calf	40	10	50	None	DVT
Iwama et al. (2004)	SC	Calf	60	10–20	50	None	DVT
Jawad et al. (2014)	IPC	Calf, peroneal nerve region	40	12–13	47–48	None	DVT
Kappa-Markovi et al. (2021)	IPC	Leg	40	15	-	None	Varicose vein surgery
Kim et al. (2022)	IPC	Leg	40–100	3–6	3–7	Discomfort	Lymphedema
Kitayama et al. (2017)	SC	Lower limb	45–90	30	20	Discomfort	Lymph drainage
Kohro et al. (2002)	SC, IPC	Leg	45–130	3–12	-	None	DVT prophylaxis
Kohro et al. (2003)	SC	Leg	45–130	12	-	None	DVT prophylaxis
Kohro et al. (2005)	IPC	Leg, soles	130	3	-	None	DVT prophylaxis
Koo et al. (2014)	SC	Leg	40–45	12	48	DVT	DVT prophylaxis
Kozdağ et al. (2012)	EECP	Calves, thighs, buttocks	280–300	diastolic phase	systolic phase	None	CHF
Kurtoglu et al. (2005)	IPC	Calf	40	90	30	PE, leg edema	VTE
Labropoulos et al. (2005)	IPC	Calf, foot	120	3	-	Severe pain, popliteal vein reflux, discomfort	Critical limb ischemia
Li et al. (2024)	IPC	Lower limbs	40–60	15	-	None	DVT prophylaxis
Loh et al. (2006)	EECP	Calves, thighs, buttocks	260–300	diastolic phase	systolic phase	Leg pain, superficial ecchymosis, cellulitis	Chronic stable refractory angina
Mayrovitz et al. (2007)	SC	Forearm	45	30	-	None	Lymphedema
Meisinger et al. (2017)	SC	Calf	40	12	48	None	Lymphangiography
Morris et al. (2002)	IPC	Thigh, calf	60	10	50	None	PAD
Morris et al. (2004)	IPC	Thigh, calf	60	10–60	50–60	None	PAD
Murakami et al. (2003)	SC, IPC	Calf	50	8.0–11.0	52–60	None	DVT prevention
Nakanishi et al. (2016)	IPC	Thigh	50	10	50	None	DVT prophylaxis
Nandwana et al. (2019)	IPC	Arm	30–45	12	48	None	Muscle tissue oxygenation
Ogawa et al. (2005)	SC	Foot, calf	80	6	-	PE, mild calf pain, sleeplessness	DVT
Patterson et al. (2013)	SC	Thigh, calf	45–30	11	60	None	VTE prophylaxis
Pawlaczyk et al. (2015)	IPC	Foot	50–72	4	15	None	Chronic leg ischemia
Pitto et al. (2008)	IPC	Foot	130	1	-	DVT, PE, minor bleeding, discomfort	DVT prophylaxis
Praxitelous et al. (2018)	IPC	Foot, calf	40–130	1.0–11.0	20–49	None	Lower limb hemodynamics
Rampengan et al. (2015)	EECP	Calves, lower thigh, upper thigh	300	diastolic phase	systolic phase	Cardiovascular events	CHF
Rifkind et al. (2014)	IPC	Foot, calf	120	4	16	Superficial ecchymosis	Systemic vascular and endothelial function
Rithalia et al. (2002)	IPC	Leg	6–124	12–50	45–60	None	DVT, edema, venous ulcer
Sanal-Toprak et al. (2019)	IPC	Arm	50–80	60	25	Cellulitis	Breast cancer-related lymphedema
Schwenk et al. (2000)	SC	Thigh	40	11	60	None	DVT
Sheldon et al. (2012)	IPC	Foot, calf	120	2–3	3–17	DVT, discomfort	PAD
te Slaa et al. (2011)	IPC	Foot	130	0.4	-	Local skin damage	Postoperative edema management
Stys et al. (2002)	EECP	Calves, thighs, buttocks	225–275	diastolic phase	systolic phase	None	Chronic stable angina
Tartaglia et al. (2003)	EECP	Calves, lower thighs, upper thighs / buttocks	250–300	diastolic phase	systolic phase	None	Chronic stable angina
Urano et al. (2001)	EECP	Calves, thighs, buttocks	300	diastolic phase	systolic phase	Contact dermatitis	coronary artery disease
Williams et al. (2014)	IPC	Calf, ankle	45	11	-	Discomfort	Circulatory improvement
Zaleska et al. (2013)	IPC	Leg	50–120	50	50	None	LLL
Zaleska et al. (2014)	IPC	Leg	120	50	50	None	LLL
Zaleska et al. (2015)	IPC	Leg	120	50	50	None	LLL
Zhou et al. (2023)	IPC	Feet, Calf, thigh	80–140	5–15	-	None	DVT prevention
CHF – Chronic heart failure, CLI – Critical limb ischemia, DVT – Deep vein thrombosis, EECP – External enhanced counter pulsation, IC – Intermittent claudication, IPC – Intermittent pneumatic compression, LLL – Lower limb lymphedema, PAD – Peripheral arterial disease, PE – Pulmonary embolism, SC – Sequential compression, VTE – Venous thromboembolism

Table 2
Summary of included surgical studies utilizing pneumatic tourniquet systems
Author	Device type	Device location	Cuff pressure (mm Hg)	Duration (minutes)	Complications	Therapeutic action
Ajwani et al. (2012)	Tourniquet	Thigh	300	90–110	None	TKA
Alexandersson et al. (2018)	Tourniquet	Thigh	300	~ 99	None	TKA
Bae et al. (2023)	Tourniquet	Upper arm/thigh	200–300	< 120	Increased postoperative pain	Ortho-limb surgery
Besir et al. (2019)	Tourniquet	Thigh	180–221	70–90	Increased intracranial pressure	Orthopedic lower-extremity surgery
Binabdrazak et al. (2014)	Tourniquet	Thigh	300	72	DVT, PE	TKA
Boiko et al. (2004)	Tourniquet	Upper arm	250–350	14	None	Hand surgery
Brix et al. (2022)	Tourniquet	Thigh	250	5–21	None	Transfemoral amputation
Chaiyakit et al. (2024)	Tourniquet	Thigh	250	60–70	Wound-related	TKA
Choksy et al. (2006)	Tourniquet	Thigh	120–150	75	Hematoma	Transtibial amputation
Cousins et al. (2015)	Tourniquet	Upper arm	250	8–10	Bleeding, pain	Carpal tunnel decompression
de Souza et al. (2016)	Tourniquet	Thigh	350, SBP + 100	110–118	Higher systemic inflammation, muscle injury	TKA
Drosos et al. (2013)	Tourniquet	Upper limb	SBP + 100	10	None	Carpal Tunnel Surgery
Edwards et al. (2000)	Tourniquet	Arm, forearm	250	20	Pain	Hand surgery
Girardis et al. (2000)	Tourniquet	Thigh	350	75–108	Hemodynamic instability, metabolic disturbances	Knee ligament surgery
Huang et al. (2014) [59]	Tourniquet	Thigh	280–300	107–112	DVT, wound, pain	TKA
Huang et al. (2014) [60]	Tourniquet	Thigh	SBP + 100	11–88	Muscle damage, inflammatory response, wound infection	TKA
Kadoi et al. (2009)	Tourniquet	Thigh	450	90	Increased intracranial pressure, acute metabolic changes	Orthopedic
Kanchanathepsak et al. (2023)	Tourniquet	Arm	LOP + (50 to 100), 250	14–16	Pain, discomfort, soft tissue injury, nerve damage	Minor hand surgery
Kasem et al. (2019)	Sequential compression	Thigh	208–283	68	None	Orthopedic
Lee et al. (2017)	Tourniquet	Thigh	143–164	67	Pain, swelling, blisters, skin redness	TKA
Leon et al. (2018)	Tourniquet	Thigh	286–350	98–102	None	TKA
Matsui et al. (2021)	Tourniquet	Thigh	250	116–118	Pain, skin complications	TKA
McEwen et al. (2002)	Tourniquet	Calf	142–250	52	skin complications	Lower limb procedures
Mori et al. (2016)	Tourniquet	Thigh	250	64	DVT	TKA
Natesan et al. (2024)	Tourniquet	Thigh	LOP+ (40–80), SBP + 150	46	Pain, swelling	TKA
Olivecrona et al. (2012)	Tourniquet	Thigh	150–300	87	Wound complications, blister, nerve injury, DVT	TKA
Olivecrona et al. (2013)	Tourniquet	Thigh	237	81	Nerve injury	TKA
Park et al. (2020)	Tourniquet	Thigh	215–221	50	DVT, thigh pain	TKA
Reilly et al. (2009)	Tourniquet	Thigh	151–300	90	Pain, delayed functional recovery	Pediatric ACL reconstruction
Saenz-Jalón et al. (2017)	Tourniquet	Arm	300	66	Pain, hyperemia	Upper limb orthopedic procedures
Takada et al. (2007)	Tourniquet	Thigh	350	100	Pain, inflammation	TKA / ACL reconstruction
Tetro et al. (2001)	Tourniquet/blood pressure cuff	Thigh	SBP+ (125–150)	83	Wound infections, skin blistering, wound hematomas	TKA
Tuncali et al. (2003)	Tourniquet	Arm	118–270	116	None	Upper limb orthopedic surgery
Vaishya et al. (2018)	Tourniquet	Thigh	SBP + 150	13–44	Pain, swelling, redness	TKA
Van et al. (2008)	Tourniquet	Thigh	300	79	Pain	Elective knee surgery
Wu et al. (2022)	Tourniquet	Thigh	(SBP + 10 mmHg)/KTP; SBP + 100; 300	77	Muscle injury, pain, delayed functional recovery	TKA
Yıldırım et al. (2024)	Tourniquet	Thigh	191–247	94–102	Pain, delayed functional recovery	Foot and ankle surgery
Younger et al. (2004)	Tourniquet	Thigh	202–242	100–125	Cuff pain	Foot and ankle surgery
Younger et al. (2011)	Tourniquet	Thigh	199–260	68	None	Elective foot and ankle operations
Zhang et al. (2017)	Tourniquet	Thigh	316–322	91	DVT, intramuscular vein thrombosis	TKA
Zhelun et al. (2024)	Tourniquet	Upper and lower limbs	180–300	70–76	DVT, delayed wound healing, pain	Orthopedic trauma extremity surgery
ACL – Anterior cruciate ligament, DVT – Deep vein thrombosis, LOP – Limb occlusion pressure, PE – Pulmonary embolism, SBP – Systolic blood pressure, TKA – Total knee arthroplasty

Table 3
Diagnostic applications of pneumatic compression in clinical studies
Study	Device type	Device location	Cuff pressure (mm Hg)	Therapeutic action
Bhamidipaty et al. (2015)	Cuff-based pressure measurement system	Toe	200	Peripheral arterial disease diagnosis
Bilecen et al. (2004)	Standard sphygmomanometer cuff	Calf	50	MRI enhancement aid
MRI – Magnetic resonance imaging

Table 4
*Summary of studies investigating pneumatic compression for blood flow restriction and sports recovery*
Study	Device type	Device location	Cuff pressure (mm Hg)	Duration (minutes)	Complications	Therapeutic action
Abbas et al. (2022)	Tourniquet	Upper arm, thigh	120–180	-	None	BFR Therapy
Barbosa et al. (2018)	BFR cuff	Upper arm	50% of SBP	-	None	Vascular training for AV fistula preparation
Bentzen et al. (2023)	BFR	Thigh	60% of LOP	2	None	Intermittent claudication management
Brander et al. (2014)	BFR	Arm	80%–130% of SBP	-	Discomfort, muscle soreness	Muscle strength and hypertrophy training
Jønsson et al. (2024)	BFR	Thigh	40% of AOP	45	Discomfort	Muscle rehabilitation in chronic SCI
BFR – Blood flow restriction, SBP – Systolic blood pressure, LOP – Limb occlusion pressure, AOP – Arterial occlusion pressure, AV – Arteriovenous, SCI – Spinal cord injury

Cuff pressure and inflation duration across applications

Cuff pressure and inflation duration are critical parameters that influence the physiological effects and clinical outcomes of pneumatic compression therapy. These parameters vary widely depending on the device type, anatomical location, clinical indication, and intended application (therapeutic, surgical, diagnostic, or sports-related). The following subsections summarize the ranges and distributions of cuff pressures and inflation times reported across the included studies, categorized by their respective application areas.

Therapeutic application

In therapeutic applications, the cuff pressure ranged from 35 mmHg to 300 mmHg, with a median of 87.5 mmHg. Inflation durations varied from 0.4 seconds to 90 seconds, with a median of 8 seconds. The wide range reflects the differences in clinical indications and device protocols. For example, higher pressures were often used in PAD management and EECP therapy. Figure 2 presents box plots summarizing the cuff pressure and inflation time in therapeutic studies.

Surgical application

Surgical applications primarily employed tourniquet systems, with cuff pressures ranging from 150 mmHg to 450 mmHg, with a median of 120 mm Hg. Inflation durations ranged from 9 minutes to 120 minutes with a median of 77 minutes, particularly during orthopedic procedures such as total knee arthroplasty (TKA). Figure 3 illustrates the distribution of cuff pressures and inflation durations in surgical applications.

Diagnostic application

Two studies were classified under diagnostic use. Reported cuff pressures were 50 mmHg and 200 mmHg, while inflation duration was either brief or not explicitly stated. Though limited in number, these studies demonstrate potential roles for pneumatic compression in enhancing diagnostic accuracy.

Sports medicine application

Sports medicine applications involved BFR therapy, aimed at enhancing muscle strength, vascular function, or recovery. These studies used cuff pressure values expressed as a percentage of SBP or LOP, ranging from 40% to 130%. Inflation durations ranged between 2 and 45 minutes.

This systematic review comprehensively analyzed the use of pneumatic compression devices across four major application domains: therapeutic, surgical, diagnostic, and sports medicine. The primary goal was to evaluate and summarize reported cuff pressures and inflation times, key parameters that influence the physiological outcomes and clinical effectiveness of compression-based interventions.

The majority of the included studies focused on therapeutic applications, reflecting the widespread use of pneumatic compression in managing conditions such as VTE prophylaxis [23, 36, 72], DVT prevention/treatment [21, 40, 67], PAD [7, 17, 42], lymphedema management [79, 113, 114], chronic venous insufficiency / ulcers [97], postoperative recovery [120], and heart failure or angina [14, 33, 71]. These studies demonstrated a wide variation in both cuff pressure (30–300 mmHg) and inflation duration (0.4–90 seconds), emphasizing the absence of standardized treatment protocols. IPC was the most commonly used device, highlighting its clinical importance, especially in vascular and lymphatic therapies. However, high pressures applied across the calf (popliteal artery) and thigh (femoral artery) regions have been associated with complications such as pain, discomfort, and skin damage in some therapeutic and surgical applications.

In surgical studies, tourniquet systems were employed using much higher pressures (up to 450 mmHg) and longer inflation durations, sometimes exceeding 120 minutes. This practice, though common, warrants caution due to potential complications such as nerve injury or ischemia. Interestingly, many surgical protocols still rely on fixed pressure settings [15, 27, 65, 88, 116] or determine the occlusion pressure [104] using the formula (SBP + 10 mmHg)/K_tp, where K_tp is the tissue padding coefficient, underscoring a potential area for protocol optimization and evidence-based refinement.

Diagnostic applications of pneumatic compression remain sparse, with only two studies identified. These investigations demonstrated the use of compression to augment vascular imaging [9] and hemodynamic assessment [26], indicating a promising but underexplored application space. Similarly, sports medicine studies, though limited in number, revealed an innovative use of BFR therapy, employing pressure values expressed as a percentage of SBP or LOP. These studies suggest growing interest in pneumatic compression for athletic performance and rehabilitation, but they also highlight significant variability in how pressure is measured and reported.

The observed heterogeneity in pressure application and inflation durations across clinical categories highlights the need for standardized reporting and device use protocols. In therapeutic and surgical contexts, variability in settings may affect treatment efficacy and safety. In emerging applications such as sports medicine and diagnostics, clearer guidance could promote more consistent implementation and facilitate further research. Manufacturers, clinicians, and researchers should work collaboratively to define optimal compression settings tailored to the patient’s condition, anatomical site, and intended therapeutic effect.

Limitations:

This systematic review presents several limitations. Due to heterogeneity in study designs, device types, and clinical indications, which hindered the ability to perform quantitative synthesis or meta-analysis. Many studies lacked standardized reporting of pressure calibration methods (e.g. SBP, LOP), device brand specifications, or patient-specific adjustments, making direct comparisons challenging.

This systematic review is the first to comprehensively analyze cuff pressure and inflation duration settings in pneumatic compression systems across therapeutic, surgical, diagnostic, and sports medicine applications. The findings underscore a broad range of device settings, with therapeutic pressures typically falling between 30 and 120 mmHg, high-pressure modalities such as EECP reaching up to 300 mmHg, and surgical tourniquet systems exceeding 350 mmHg.

Despite the clinical utility of these systems, there is a clear absence of standardized, evidence-based guidance on optimal pressure and duration settings. This inconsistency poses a challenge to both clinical practitioners and biomedical engineers developing next-generation therapeutic devices.

For engineers designing wearable or AI-enabled systems, particularly those designed for conditions such as diabetic foot ulcer (DFU) and PAD, this review provides foundational data to inform safe and effective pressure thresholds. Devices such as EECP demonstrate that higher pressures can be beneficial in specific cases, but they also reinforce the importance of proper patient selection and risk management.

Future research should focus on:

establishing safety thresholds and dose–response relationships for different patient groups;
incorporating patient-specific calibration (e.g., using SBP or LOP);
standardized reporting of adverse events and long-term outcomes;
developing techniques for the integration of real-time monitoring of pressure and compliance.

By addressing these gaps, the medical and engineering communities can jointly advance pneumatic compression therapy as a safer, more personalized modality across multiple domains.

BFR Blood Flow Restriction

DFU Diabetic Foot Ulcer

DVT Deep Vein Thrombosis

EECP Enhanced External Counter-pulsation

IPC Intermittent Pneumatic Compression

LOP Limb Occlusion Pressure

MRI Magnetic Resonance Imaging

PAD Peripheral Arterial Disease

PE Pulmonary embolism

SBP Systolic Blood Pressure

SCD Sequential Compression Device

VTE Venous Thromboembolism

Authors' contributions: A.C., H.L.L., and D.K. conceptualized and designed the study. A.C. and D.K. conducted the literature search. A.C., H.L.L., and D.K. performed screening processes. A.C. and D.K. performed data extraction and processing. A.C. and D.K. prepared the first draft of the manuscript. All authors assisted in drafting the final version and provided critical revisions of the article.

Sources of Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of Interest: The authors declare no conflict of interest.

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The authors declare potential competing interests as follows: Dr Albert Chong is the founder of Triphasic Medical Pte Ltd a MedTech startup developing non-invasive solutions device to improve blood circulation of the lower limbs.

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A Systematic Review of Pneumatic Compression Systems: Identifying Safe Cuff Pressures and Inflation Durations for Clinical and Biomedical Applications

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