Known+DVT+and+Ambulation

__**What is a deep vein thrombosis (DVT)?**__
 * A DVT is a condition in which a blood clot forms in one or more of the deep veins in your body. Typically this occurs in the lower legs, thigh, or pelvis, but they can also occur in the arm.


 * __Causes?__**
 * Anyone can get it! However there are predisposing factors that can increase the likelihood.
 * Injury to a vein: often caused by fractures, severe muscle injury, or major surgery (particularly involving the abdomen, pelvis, hip, or legs)
 * Slow blood flow: often caused by confinement to bed due to a medical condition or after surgery, limited movement, sitting for a long period of time especially with crossed legs, or paralysis
 * Increased estrogen: can be caused by birth control pills, hormone replacement therapy, and pregnancy for up to 6 weeks after giving birth
 * Certain chronic medical illnesses: heart disease, lung disease, cancer and it's treatment, IBD
 * Other factors: previous DVT/PE, family history of DVT/PE, advanced age, obesity, a catheter located in a central vein, or inherited clotting disorders


 * __Severity?__**
 * A DVT can be extremely serious if not fatal should the clot break loose causing an embolus that travels through the bloodstream, lodge into the lungs, and result in blocking blood flow. If the embolus is small it may only cause a small blockage but if it is large enough it can cause total blockage and be fatal. Even if a pulmonary embolism (PE) is not fatal, it can still cause permanent damage to the lungs.



__**DVT Prevention/Intervention**__
 * Movement as soon as possible after bed confinement
 * If you have known risk factors, talk to your doctor about precautions
 * When sitting for long periods of time, get up and move every 2-3 hours
 * Maintain a healthy weight and avoid a sedentary lifestyle
 * Medication - anticoagulants/blood thinners such as Warfarin and Heparin
 * Graduated compression stockings
 * Surgical removal
 * Vena Cava filter



ü VTE is defined as deep vein thrombosis (DVT), pulmonary embolism (PE), or both. ü VTE can occur in all ages, both genders, and all races/ethnicities. ü VTE is a growing health problem due to known risk factors increasing in society (immobility, obesity, advanced age, surgery, etc.) ü The number of individuals affected by VTE is based on the analysis of clinical administrative databases and community and hospital based studies. It is estimated that 300,000-600,000 individuals in the U.S. are affected each year. (1-2 per 1000 people). Due to the difficulty in documenting DVT & PE and the limitations of administrative databases, the number of VTE cases may be under-reported. ü Incidence varies when we take age, sex, and race/ethnicity into account.
 * __Prevalence of Venous Thromboembolism (VTE)__**
 * 1/100,000 young individuals VS 1/100 individuals over 80 years of age.
 * Slightly higher incidence rate in men than women, but women have a slight increase in incidence during their reproductive years.
 * Higher incidence among Caucasians and African Americans than among Hispanic persons and Asian-Pacific Islanders.
 * Table: estimated incidence of venous thromboembolism by age, race, and gender:
 * = __** Characteristics **__ ||= __** Annual incidence per 1000 **__ ||
 * = ** Race/ethnicity ** ||=  ||
 * = White ||= 1.173 ||
 * = Black ||= 0.77 6 –1.41 5 ||
 * = Asian ||= 0.29 7 ||
 * = Hispanic ||= 0.61 7 ||
 * = ** Age (years) ** ||=  ||
 * = <15 ||= <0.5 3 and 8 ||
 * = 15–44 ||= 1.493 ||
 * = 45–79 ||= 1.92 9 ||
 * = ≥80 ||= 5–6 3, 4 , 8 and 9 ||
 * = ** Gender ** ||=  ||
 * = Male ||= 1.33 ||
 * = Female ||= 1.13 ||
 * = Overall ||= 1–2 3, 4 and 5 ||

ü An estimated 2/3 of VTE patients present with DVT and 1/3 present with PE. ü An estimated 10-30% of VTE patients suffer mortality within 30 days (most deaths among those with PE). Estimated 20-25% of all PE cases present as sudden death. ü PE is the leading cause of preventable hospital death and is a leading cause of US maternal mortality. ü About 1/3 of VTE patients experience a recurrence within 10 years of the first event (even after anticoagulant therapy). Once the patient has experienced an initial VTE, they are at risk for reoccurrence for the rest of their life. ü 1/3 – 1/2 of LE DVT patients develop chronic venous insufficiency & post-thrombotic syndrome. With these conditions they will experience swelling, ulcers, skin necrosis, and pain. ü It is reported that quality of life decreases up to 4 months after DVT. ü There is no data with the exact cost of VTE, but estimated to be about $7594 to $16,644 per patient per year. Therefore anywhere between $2-10 billion can be attributed to VTE annually when we take into account the total number of VTE patients.

__**Complications of DVT**__ ü Pulmonary Embolism ü Post-thrombotic syndrome ü Less common DVT complications include:
 * Signs and symptoms include:
 * rapid breathing or sudden shortness of breath, even at rest
 * sudden rapid heart rate
 * sudden cough (which can produce bloody sputum)
 * chest pain which may be worse with coughing, deep breaths, bending, and eating
 * PE can lead to even more serious complications, such as:
 * Pulmonary hypertension (high blood pressure in lung arteries)
 * Breathing difficulties
 * Heart palpitations
 * Heart failure/cardiogenic shock
 * Signs and symptoms include:
 * Pain
 * Edema
 * Skin ulcers
 * Varicose veins
 * Hyperpigmentation (darkened skin color)
 * Recurring DVT or PE
 * Renal vein thrombosis
 * Blood clot in brain à leading to stroke
 * Blood clot in heart  à heart attack

__**Goals of DVT Treatment**__ ü Preventing a clot from growing ü Preventing a clot from breaking off and traveling to the lung or other organ ü Avoiding long-lasting complications, such as [|__leg pain__] and swelling ü Preventing blood clots from recurring

__**Bed Rest**__ ü Traditionally, patients with active DVT have been immobilized and placed on bed rest for 7-10days. However, this approach has been challenged by studies that show a better clinical outcome with ambulation and compression. In the past, bed rest was the preferred method of treatment for DVT patients because it was feared that activity would cause the patient to develop a PE. The belief that immobilization relieves swelling and local pain also supported bed rest as a treatment for DVT.

ü We now have data that suggests that early mobilization does not increase the incidence of new PE in patients with DVT, but some are still hesitant to begin ambulation immediately after a DVT diagnosis.

ü The American College of Chest Physicians (ACCP) does not recommend bed rest in its guidelines for treating acute venous thromboembolism, but rather ambulation as tolerated after beginning anticoagulation.

ü In practice, there is no standard protocol for progression of activity in a patient with a known DVT.

__**Deciding when a patient can safely begin ambulation**__

ü The PT and physician caring for the patient with DVT must ask the following questions before they decide when it is safe to begin ambulation:
 * Is the patient receiving adequate medical treatment for DVT?
 * Will ambulation place the patient at increased risk of acute PE?
 * Should a PE occur during the course of intervention, will the patient be able to tolerate this insult?
 * Will continued bed rest place the patient at increased risk of progressive DVT and at increased risk for the other complications of bed rest?
 * Does the patient have evidence of PE before beginning ambulation?


 * __When Can Ambulation Begin Following a DVT?__**

Data regarding early ambulation and the appropriate time following a DVT is limited. As of now, the most appropriate time to begin ambulation is based upon the professional judgments of both the physician and the physical therapist. If the patient is receiving medical treatment such as an anticoagulant and has no signs of pulmonary embolism, then early ambulation can be considered as well as be the more beneficial approach. Information regarding the intensity of ambulation is still limited and more research should be done in order for physical therapists to use evidence-based practice (Aldrich & Hunt, 2004).

It is important to recognize that treatment is not ambulation alone. Most studies that address ambulation as an intervention is combined with medications such as heparin and vitamin K antagonists as well as compression. Since intervention is a combination of factors it is hard to figure out the exact benefits that arise from ambulation alone.
 * __Benefits of Ambulation as an Intervention to DVT__**

However, the risks of bed rest and immobilization are known, which can be prevented by exercise, such as ambulation. In a study by Dittmer and Teasell complications of bed rest result in musculoskeletal problems, including a decrease in muscular strength and endurance as well as a development of contractures and soft tissue changes. The study also showed that complications can be as severe as disuse osteoporosis, degenerative joint disease, and cardiovascular complications including an increased heart rate, decreased cardiac reserve, and orthostatic hypotension. In addition to the risks of bed rest, the rate of recovery from these complications is much slower than the rate of loss. This suggests that ambulation provides meaningful benefits as long as there is not a risk of developing a pulmonary embolism.

Current studies have shown that ambulation as a treatment improves well-being and quality of life more quickly than bed rest alone and does not pose additional risks of pulmonary embolism. In a study by Blattler and Partsch, ambulation, along with compression and medications, as a treatment for DVT posed better benefits than bed rest and medications alone. The study was conducted over 9 days with ambulation increasing up to 4km/day opposed to bed rest. The study had 3 groups; ambulation and inelastic bandages for compression, ambulation and elastic compression stockings, and bed rest without compression. Pain decreased with time over all the groups (p<0.001). However, there was a significant difference (p<0.01) between the groups, with the bandages and ambulation providing the greatest benefit. With the bed rest group pain was reduced by half on day 3 then remained constant for the remaining study, whereas with compression pain was reduced to near baseline on day 3. Swelling was also reduced with compression (p<0.001). Thrombus progression was assessed with ultrasound and found that it was less frequent in the groups with compression and ambulation (Blattler & Partsch, 2003).  [|**http://www.youtube.com/watch?v=aW6WscFqli8**] (~minute 3) The fear of ambulation as an intervention to DVT is that the clot will break away and move through the blood stream and result in blocking a lung artery known as pulmonary embolism. However, recent studies have shown that ambulation does not increase the risk of PE. In the previous study by Blattler and Partsch there was no difference of new PE on lung scans. Additionally, a systematic review by Anderson, Overend, Godwin, Sealy, and Sunderji showed that there was not a significant difference in developing a new PE between mobilization and compression vs bed rest and compression as well as no significant difference in the progression of an existing DVT (Anderson, Overend, Godwin, Sealy, & Sunderji, 2009).
 * __Risks of Ambulation as an Intervention to DVT__**

Clinical judgment is very important in weighing the pros and cons of ambulation in patients with a DVT. These patients should also be closely monitored for changes in status when being ambulated during the initial acute phase. The therapist should be confident that ambulating patients with DVT does not appear to increase the risk of developing a PE, progression of an existing DVT, or developing a new DVT. Some signs and symptoms therapist should be aware of when ambulating with a patient independently or with an assistive device is:
 * pain (aching or cramping)
 * heaviness
 * itching or tingling
 * swelling (edema)
 * varicose veins
 * brownish or reddish skin discoloration
 * ulcer

These signs and symptoms may vary among patients and over time. The pain can get worse after walking or standing for long periods of time.

There is evidence that early walking exercise can be started in patients with uncomplicated DVT within the first 24 hours after appropriate anticoagulant treatment and use of compression garments. The average daily walking distances of 600–12,000 meters have been associated with improvements in pain and swelling with no increased risk of PE, compared with bed rest. It is encouraged that people do not attempt exercise of any kind without first seeking the advice of your treating physician.
 * __ How far can you walk? __**

__** Early ambulation, is it safe? **__ Two randomized controlled trials have demonstrated that there was no statistically significant difference between the frequency of new PEs compared to a baseline lung scan ventilation-perfusion called if patients with proximal DVT are treated with LMWH and either kept in bed or ambulated with leg compression. In one study, 129 patients with proximal DVT were randomized to either immobilization for 4 days or ambulation for 4 hours per day under supervision with a compression bandage. All patients were screened for PE at baseline and at day 4 by lung scans, and these were followed up at 3 months. The frequency of PE at baseline was 53.0% and 44.9% in the bed rest and ambulatory groups. During the 4-day observation period, new PEs were found in 10% of bed-rest patients and in 14.4% of those who were ambulated (difference, 4.4%; 95% confidence interval [CI] −0,5 to 13,8; χ2 = 0,569, //P// = .44). 12/16 new PEs occurred among patients with a positive lung scan at baseline. All patients with a PE were asymptomatic. No patients died during the 4-day observation period. After 3 months, two patients from the bed-rest group and three from the ambulating group died. Malignancy was the cause of death for all participants. The authors of the article conclude that occurrence of PE is not increased by early ambulation and suggest that early mobilization is safe.

In a prospective cohort study 1,289 consecutive, mobile patients admitted with acute symptomatic DVT. All patients were treated with LMWH, compression, and immediate ambulation. V/Q scans were performed at admission and repeated after 10 days. On admission positive lung scans were found in 190 of 356 (53.4%) patients with iliofemoral, the difference between patients with proximal venous thrombosis compared to patients with isolated lower leg vein involvement was statistically highly significant (//P// <. 001). After 10 days new PEs were seen in 7.4%, 6.4%, and 3.4% of patients. Only 6 of 77 patients with scan-detected new PEs had mild pulmonary symptoms. Seventeen patients (1.3%) in this series died during hospital stay and all underwent autopsy. Only three of these deaths were attributed to pulmonary emboli (0.23%) and all patients were older than 76 years. Twelve patients died from malignancy.

In a study from Schellong et al,[|11] patients with proximal DVT were randomly assigned to strict bed rest for 8 days or to begin full ambulation at day 2. All patients received LMWH, overlapping with oral anticoagulants and compression therapy using elastic bandages or compressive stockings. Ventilation scans were done on day 1 and days 8 to 10. Sixty-two patients were randomly assigned to a group that received 8 days of bed rest and anticoagulation and 64 to a group that performed ambulation beginning on the second day after the initiation of LMWH. New PEs were detected in 10 of 59 patients assigned to the group that received bed rest and in 14 of 63 patients from the ambulatory group (//P// < .25; power, 0.8). PE was symptomatic in one patient in the bed-rest group. The prescription of bed rest as a form of treatment of DVT does not reduce PE’s enough to have a died from malignancy. Table 1. Randomized Controlled Trials Investigating the Frequency of Pulmonary Embolism in DVT Patients Treated by Bed Rest or Mobilization*
 * |||| ** Schellong et al **

|||| ** Aschwanden et al **

|||| ** Partsch et al **

|| DVT, deep vein thrombosis; PE, pulmonary embolism. All patients received low-molecular-weight heparin. PEs were assessed by repeat ventilation/perfusion single photon emission-computed tomography∥ or V/Q scan. [|7] and [|10] There was no statistically significant difference between the mobile and bed-rest groups.
 * ^  ||  ** Walking after Day 2 **  ||  ** Bed Rest 8 Days **  ||  ** Immediate Walking **  ||  ** Bed Rest 4 Days **  ||  ** Immediate Walking **  ||  ** Bed Rest 9 Days **  ||
 * Proximal DVT (n) || 63 || 59 || 69 || 60 || 36 || 17 ||
 * Compression || Bandages or stockings || 0 || Bandages ||  || Bandages or stockings || 0 ||
 * PE (before therapy) || 62% || 71% || 45% || 53% || 75% || 53% ||
 * New PE (second scan) || 22% day 8-10 || 17%, day 8-10 || 14%, day 4 || 10% day 4 || 8.3% day 10 || 5.9% day 10 ||
 * Symptomatic new PE || 0 || 1.7% || 0 || 0 || 0 || 0 ||

The above data shows that the threat of fatal PE is minimal when ambulatory patients with acute DVT receive properly dosed LMWH and walk with compression bandages or stockings. An important thing to remember is to make sure that the ambulating DVT patient walks with appropriate compression.

__**Ambulation and Compression related to fast pain relief and swelling**__ A randomized controlled trial on 53 patients with proximal DVT, compared patients who were on bed rest for 9 days without compression with walking exercises either using compression stockings or bandages. All the patients received LMWH. Thrombus size was initially assessed on days 0 and 9. An increase in the length of the thrombus in the femoral vein was seen in 40% of the patients and 28% of those who walked with compression bandages. Due to the small number of patients, the difference was not statistically significant but the thrombus size showed a statistically significantly greater enlargement in those patients confined to bed compared to ambulatory patients with compression therapy (//P// < .01).

This study have shown that with strong compression of their legs, patients could walk better immediately after 9 days. More information was gathered about the patient’s pain levels as well as ambulation. The pain levels were significantly lower in the compression groups compared with the bed-rest group and the swelling in the legs decreased. Pain level was assessed by a visual scale and also by the application of increasing pressure to the calf using a blood pressure cuff. Both methods showed much faster pain reduction in the walking groups, especially in the first 3 days. In contrast to the walking groups with compression, which showed a continuous pain relief starting in the first days, this test revealed a constantly elevated level of leg pain in the bed-rest group after 3 days of initial improvement. The difference in calf circumference between both legs was taken as a parameter for edema. Before treatment this difference was more than 2 cm on average in all three groups. After 9 days an insignificant reduction of swelling was observed in the bed-rest group while both groups treated with walking and compression were almost edema free. Although, the study indicated that there was no advisement for leg elevation in bed rest patients.

|| Early ambulation and compression: What RCTs show   Resources:
 * Subjects **
 * ** Study groups ** || ** Results ** ||
 * **129 patients with DVT, treated with LMWH**[|1] || Strict immobilization for 4 days Ambulation for ≥4 h/d, along with compression for 4 days or until swelling subsided || At 4 days: No difference in PE, leg pain, leg size, mortality At 3 months: No difference in PE, mortality ||
 * **146 patients with DVT, all anticoagulated**[|5] || Hospital treatment with 5 days of bed rest Home care with early walking and compression stockings || No difference in occurrence of new PE after 10 days ||
 * **126 patients with DVT, treated with LMWH, compression**[|6] || Strict bed rest for 8 days with leg elevation Began full ambulation on day 2 || No difference in PE ||
 * **102 patients with DVT, treated with LMWH, compression**[|4] || Bed rest for 5 days Ambulation || No differences in PE, thrombus progression, serious adverse events, or leg pain Study didn’t recruit expected number of patients Study showed a trend toward benefit from ambulation ||
 * **53 patients with DVT**[|2]**,**[|7] || Ambulation and use of firm, inelastic Unna boot bandages Ambulation and elastic compression stockings Strict bed rest for 9 days and no compression || No difference in quality of life or PE DVT-related symptoms, leg pain, and circumference improved in compression/ambulation groups No changes noted at 2 years ||
 * **72 patients with DVT, treated with anticoagulation and compression**[|3] || Daily walking exercise and weekly group exercise Control group || No difference in DVT, PE, phlebography results, or calf circumference ||
 * DVT, deep vein thrombosis; LMWH, low-molecular-weight heparin; PE, pulmonary embolism. ||

//Center for Disease Control and Prevention.// 30 November 2012. 4 April 2013. []

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Michele G. Beckman, W. Craig Hooper, Sara E. Critchley, Thomas L. Ortel, Venous Thromboembolism: A Public Health Concern, American Journal of Preventive Medicine, Volume 38, Issue 4, Supplement, April 2010, Pages S495-S501, ISSN 0749-3797, 10.1016/j.amepre.2009.12.017. (http://www.sciencedirect.com/science/article/pii/S0749379709009465)

http://www.webmd.com/dvt/deep-vein-thrombosis-complications

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Dana Aldrich, Daniel P. Hunt, When Can the Patient With Deep Venous Thrombosis Begin to Ambulate?, Journal of the American Physical Therapy Association, Volume 84, Issue 3, March 2004, Pages 268-273. (http://physther.org/content/84/3/268.full)

Rola Saab, James J. Stevermer, Susan Meadows, Should patients with acute DVT limit activity?, The Journal of Family Practice, Volume 59, Issue 1, January 2010, Pages 50-52. (http://www.jfponline.com/pages.asp?aid=8270)

M.V. Huisman, H.R. Büller, J.W. ten Cate //et al.// **Unexpected high prevalence of silent pulmonary embolism in patients with deep venous thrombosis.** Chest, 95 (1989), pp. 498–502

H. Partsch. **Therapy of deep vein thrombosis with low molecular weight heparin, leg compression and immediate ambulation** VASA, 30 (2001), pp. 195–204

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Blättler, W. (2003). Leg compression and ambulation is better than bed rest for the treatment of acute deep venous thrombosis. International angiology, 22(4), 393-400.

Aldrich, D., & Hunt, D. P. (2004). Downloaded from http://ptjournal.apta.org/ by guest on April 6, 2013, 268–273. Anderson, C. M., Overend, T. J., Godwin, J., Sealy, C., & Sunderji, A. (2009). Ambulation after deep vein thrombosis: a systematic review. //Physiotherapy Canada. Physiothérapie Canada//, //61//(3), 133–40. doi:10.3138/physio.61.3.133