Guideline Development Group

Summary of Evidence

Whether or not a VTE (i.e. LE DVT; PE; PTS) has a clear cause (e.g. surgery; trauma; forced immobilization) or is unprovoked (i.e. in the absence of a known risk factor), physical therapists should remain vigilant in screening patients for signs and symptoms of recurrent VTE.¹²⁵ It is estimated that the risk of recurrence can reach 5 to 10 percent during the first 6-12 months¹²⁶ and 10% to 30% within five years¹²⁷ following a documented first-episode VTE. According to one recent CPG, the rate of VTE recurrence for patients not on long term anticoagulation is 5% per year.³⁵ When pharmacologic anticoagulation is provided, the recurrence rate for VTE within the first 6 months is reported to be less than 2.5% in one RCT¹²⁸ and between 1.3%-7.1% over a period of 18-24 months in another RCT.¹²⁹ Nevertheless, the incidence of fatal and non-fatal VTE recurrence in patients who are anti-coagulated following confirmed VTE in the short term of 3 months was reported to be 0.4% and 3%, respectively, in one meta-analysis¹³⁰ and fatality incidence due to PE of 1.68% in a large cohort study.¹³¹ These findings serve to underscore the importance of having physical therapists monitor patients for VTE recurrence whether over the short- or long-term.

The ability of a clinician to accurately predict level of risk for recurrent VTE (e.g. low versus high) has been investigated using the Pulmonary Embolism Severity Index (PESI) clinical prediction rule and found to be of merit.^{128, 132} Additionally, the use of global clinical judgment that takes into account all of a patient’s signs and symptoms (i.e. unstructured clinician Gestalt) may be superior to clinical prediction rule use.¹²⁹

The ability to distinguish or recognize that PTS is present is important for the clinician to determine. PTS is defined as a combination of clinical signs and symptoms occurring after a LE DVT. One study examined 6 different scoring systems that are intended to document the presence and severity of PTS based on variable clinical signs (i.e. eleven) and symptoms (i.e. twelve) used between them.¹¹³ Since PTS also involves a patient’s subjective report of symptoms, using the objective PTS indicator of skin pigmentation changes that highly correlate with findings from duplex sonography for venous-reflux occlusion, was advocated.

Thrombosis resolution is often incomplete with as many as 50% of legs affected by DVT still having residual vein thrombosis years after the LE DVT is first diagnosed.⁹⁷ The negative impact on generic life- quality measures (e.g. SF-36 Health Survey sections for physical functioning and bodily pain) has life-quality consequence comparable to chronic medical conditions such as diabetes and heart failure.¹¹⁶ It is prudent, therefore, that physical therapists recognize signs and symptoms of PTS and intervene with education, hydration, early mobilization, mechanical compression, and referral for medication when appropriate (Refer to Key Action Statement 3). For example, mechanical compression aims to manage factors responsible for the pathogenesis of VTE (i.e. Virchow’s triad of hyper-coagulopathy, venous stasis, and endothelial damage) by reducing swelling, accelerating venous return, and improving muscle pump function.¹²¹

In summary, patients who have a prior history of VTE are at high risk of recurrent VTE, especially when they are immobilized and/or are of advanced age. It is judicious to screen for VTE recurrence using a clinical prediction rule (e.g. PESI; Padua; Wells’ Criteria for LE DVT; Geneva) for objective documentation purposes, although global clinical judgment that would favor intervention for secondary VTE prevention should not be overlooked. Once VTE is diagnosed, clinical practice has shifted away from immobilization with bed rest and toward early ambulation with or without adjunctive mechanical compression. From the literature examined, the degree to which recurrent VTE is treated as a secondary prevention should be a priority. Thus, clinical judgment and expert opinion remain for deciding the clinical actions to take.