Guideline Development Group



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The Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed with Venous Thromboembolism – An Evidence-Based Clinical Practice Guideline

Guideline Development Group:


Ellen Hillegass, PT, PhD, CCS, FAPTA - Mercer University, Atlanta, Georgia

Michael Puthoff, PT, PhD, GCS - St Ambrose University, Davenport, Iowa

Ethel Frese, PT, DPT, MHS, CCS - St Louis University, St Louis, Missouri

Mary Thigpen, PT, PhD - Brenau University, Gainesville, Georgia

Dennis Sobush, PT, MA, DPT, CCS, CEEAA – Marquette University, Milwaukee, Wisconsin

Beth Auten – Librarian, MLIS, MA, AHIP



ABSTRACT

The American Physical Therapy Association (APTA), in conjunction with the Cardiovascular & Pulmonary and Acute Care Sections of the APTA, have developed this clinical practice guideline (CPG) to assist physical therapists in their decision making process when managing patients at risk for venous thromboembolism (VTE) or diagnosed with a lower extremity deep vein thrombosis (DVT). No matter the practice setting, physical therapists work with patients who are at risk for and/or have a history of VTE. This document will guide physical therapy practice in the prevention of, screening for and management of patients at risk for or diagnosed with lower extremity DVT (LE DVT).



Through a systematic review of published studies and a structured appraisal process, key action statements were written to guide the physical therapist. The evidence supporting each action was rated and the strength of statement was determined. Table 1 lists the 14 action statements. Clinical practice algorithms (Figures 2-4), based upon the key action statements , were developed that can assist with clinical decision making. Physical therapists, along with other members of the healthcare team, should work to implement these key action statements to decrease the incidence of VTE, improve the diagnosis and acute management of LE DVT, and reduce the long term complications of LE DVT.

Table 1: Key Action Statements


Number

Statement

Key Phrase

1

Physical therapists should advocate for a culture of mobility and physical activity unless medical contraindications for mobility exist.
(Evidence Quality: I, Recommendation Strength: Strong)

Advocate for a Culture of Mobility and Physical Activity

2

Physical therapists should screen for risk of VTE during the initial patient interview and physical examination (Evidence Quality: I ; Recommendation Strength: Strong)

Screen for Risk of VTE

3

Physical therapists should provide preventive measures for patients who are identified as high risk for LE DVT. These measures should include education regarding signs/symptoms of LE DVT, activity, hydration, mechanical compression and referral for medication.
(Evidence Quality: I, Recommendation Strength: Strong)

Provide Preventive Measures for LE DVT

4

Physical therapists should recommend mechanical compression (e.g., intermittent pneumatic compression and/or graduated compression stockings) when individuals are at high risk of LE DVT.
(Evidence Quality: I, Recommendation Strength: Strong )

Recommend Mechanical Compression as a Preventive Measure for LE DVT

5

Physical therapists should establish the likelihood of a LE DVT when the patient presents with pain, tenderness, swelling, warmth, and/or discoloration in the lower extremity.
(Evidence Quality: II; Recommendation Strength: Moderate)

Identify the Likelihood of LE DVT When Signs and Symptoms are Present


6

Physical therapists should recommend further medical testing after the completion of the Wells’ Criteria for LE DVT prior to mobilization (Evidence quality: I; Recommendation strength: Strong)


Communicate the Likelihood of LE DVT and Recommend Further Medical Testing

7

When a patient has a recently diagnosed LE DVT, physical therapists should verify if the patient is taking an anticoagulant medication, what type of anticoagulant medication, and when the anticoagulant medication was initiated.
(Evidence Quality: V; Recommendation Strength: Theoretical/foundational)

Verify the Patient is Taking an Anticoagulant

8

When a patient has a recently diagnosed LE DVT, physical therapists should initiate mobilization when therapeutic threshold levels of anticoagulants have been reached.
(Evidence Quality: I, Recommendation Strength: Strong)

Mobilize Patients who are at a Therapeutic Level of Anticoagulation

9

Physical therapists should recommend mechanical compression (e.g., intermittent pneumatic compression &/or graduated compression stockings) when a patient has a LE DVT.
(Evidence Quality: II, Recommendation Strength: Moderate)

Recommend Mechanical Compression for Patients with LE DVT

10

Physical therapists should recommend that patients be mobilized, once hemodynamically stable, following inferior vena cava (IVC) filter placement.

(Evidence Quality: V; Recommendation Strength: P-Best Practice)



Mobilize Patients post IVC filter placement once hemodynamically stable

11

When a patient with a documented LE DVT below the knee is NOT treated with anticoagulation and does NOT have an IVC filter and is prescribed out of bed mobility by the physician, the physical therapist should consult with the medical team regarding mobilizing versus keeping the patient on bed rest.

(Evidence Quality: V; Recommendation Strength: P – Best Practice).



Consult with the Medical Team when a Patient is not Anticoagulated or Without an IVC filter

12

Physical therapists should screen for fall risk whenever a patient is taking an anticoagulant medication.
(Evidence Quality: III, Recommendation Strength: Weak)


Screen for Fall Risk

13

Physical therapists should recommend mechanical compression (e.g. intermittent pneumatic compression &/or graduated compression stockings) when a patient has signs &/or symptoms (S & S) suggestive of Post-Thrombotic Syndrome (PTS).

(Evidence Quality I, Recommendation Strength: Strong)



Recommend Mechanical Compression when S&S of PTS are Present

14

Physical therapist should monitor patients who may develop long term consequences of LE DVT (e.g. PTS severity) and provide management strategies that prevent them from occurring to improve the human experience and increase quality of life. (Evidence Quality: V; Recommendation Strength: P Best Practice)

Implement Management Strategies to Prevent Future VTE


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