Clinicians like physical therapists, occupational therapists and nurses are all too familiar with the way that developing a Deep Vein Thrombosis (DVT) can slam your patient’s progress to a halt. Whether you are working with a patient in acute inpatient rehab, outpatient therapy, a sub acute setting, or in home-care, the diagnosis of a DVT comes with a lot of apprehension, fear, and mixed messages about the precautions and contraindications that may now apply.
Therapeutic treatment and rehabilitation when it comes to treating the DVT, and DVT-related complications such as swelling, are also shrouded in doubt and uncertainty. Swelling can have many different pathologies and causes, including DVT.
I have been working in rehab for over ten years and have heard all manner of clinical opinions when it comes to DVT… and its even less popular sister, Post-Thrombotic Syndrome (PTS). Most prevalent amongst therapists and nurses, however, is that if your patient has a clot, you cannot continue doing your therapy, and you absolutely cannot engage in any therapy related to the edema.
This belief may stem from the fear that many clinicians have about jarring the DVT loose, and creating a far worse problem- that of a pulmonary embolism (PE). This is a valid concern, or course, and should be mitigated against (how likely is it really, though?).
In this article:
- Deep Vein Thrombosis (DVT) and Post-thrombotic syndrome (PTS) overview
- Who is at risk for DVT?
- Complete Decongestive Therapy
- How to treat DVT-related swelling
DVTs- what they are; PTS what it is
A DVT is a blood clot, or a lump of solidified blood, which has formed in a vein. They can take as little as 3 or 4 hours to form… but can really complicate your patient’s rehab stay. As therapists/nurses, we should be aware of the risks, the signs (when there are signs) and the most effective treatments.
Who is at risk for DVT?
Risk factors for the development of a Deep vein thrombosis include a blood clotting disorder- a typically inherited condition, such as Factor V Leiden. Prolonged bed rest of immobility, such as a surgery (especially hip or leg surgery), hospital stay or a condition impacting mobility (like CVA or SCI), is also a significant risk for thrombosis- hence many patients that we see on a daily basis. Various cancers, pregnancy, hormonal medications, and smoking are all additional circumstances that may lead to development of a DVT.
DVTs are relatively common, and most are treated prophylactically with medication and compression such as TED hose. Without intervention, as many as 40-80% of surgerical cancer patients will develop DVT in the calf, while 10-20 % will develop DVT in a proximal vein- according to a report published by the Surgeon General regarding DVT and PE.
Localised swelling, redness, tenderness and a positive Homan’s sign are some of the warning signs of a DVT. A thrombus can only definitively be diagnosed, however, with Venous ultrasound (Doppler), MRI, or contrast venography.
Typical treatment for DVT includes anticoagulants (blood thinners), thrombolytic agents (which break up the clot), or surgery such as a vena cava filter or venous thromebctomy, if medication is not effective.
So that’s a DVT summary! Pretty straightforward, right?! …Not so fast.
Post-thrombotic syndrome (PTS) is a form of chronic venous insufficiency(link to 7 types article), which develops in approximately 20 to 50% those who have had a DVT. PTS presents with leg pain, leg heaviness, vein dilation, skin discoloration, venous ulcers, and edema.
Guidelines from the American Heart Association indicate that prevention of DVT, timely recognition and treatment of DVT, and prevention of recurrent DVT, will have the greatest impact on reducing PTS. Our patients, who may be post-surgical, immobile, of have had DVT, are going to be at a higher risk of chronic venous insufficiency (CVI) and PTS.
So with both DVT and PTS resulting in extensive complications, including decreased circulation and edema and the issues that arise from these, it is clear that managing the swelling is going to be a major concern. If the edema persists in the limb, the person is going to be at increased risk for DVT or PTS. Decreasing DVT-related swelling and managing the edema and circulation will be the most effective way of gaining most functional use of the limb, and improving quality of life for the person.
Edema therapy should always be a part of your care plan for a person with DVT!
Complete Decongestive Therapy (CDT)
Complete Decongestive Therapy (CDT) is the umbrella term for the therapeutic treatment of edema. It includes:
- Manual Lymphatic Drainage (MLD)– a hands-on, gentle manual therapy approach, which aims to move lymphatic fluid along the pathways in the body, reducing fluid in edematous areas.
- Compression- a system of short stretch bandages, used with soft foam, to provide localized compression to the edematous region after pathways have been opened with MLD.
- Exercise- segmental pumping exercises which harness the muscle pumping action of the limbs to move lymphatic fluid back toward proximal regions of the body.
- Skin care- Hygiene and skin care to ameliorate for specific skin conditions that are associated with chronic swelling.
- Education- Comprehensive education to the person including management of risk factors, exercises, resources, MLD and compression that can be performed independently.
CDT is the gold standard of treatment for chronic, peripheral edema- such as that found by those with DVT or with PTS.
But is CDT safe to use for DVT-related edema? Let’s take a closer look at how to modify this treatment for best results…
How to use CDT to manage DVT-related swelling
Managing the edema associated with DVT is absolutely essential. Not only will including edema control in your plan of care reduce the persons discomfort, improve mobility, and qulaoty of life; it will also work to prevent further DVTs from occurring, and decrease the likelihood of devlelopniong PTS.
Edema management of PTS and other chronic vascular insufficiencies are a major concern for the therapist and the patient. To prevent this already serious condition from worsening, we need to decrease edema and increase circulation. Secondary prevention of DVTs, through edema management, should be a high priority for any clinician.
So how do we modify the above CDT for safety with DVT-related swelling?
Well let’s first ‘bust’ the myth that compression is not a safe modality for use with acute DVT.
In fact, strong compression has been shown to have numerous benefits in treating acute DVT- including significantly decreasing pain, swelling, and improving measured quality of life. They have also been shown to reduce the clinical symptoms of Post-thrombotic syndrome, when compression bandages are applied in the acute stage of DVT, compared to no compression. (Read more studies here and here)
Physician guidelines for treatment of acute DVT stress the need for compression- however, many under-informed medical professionals use elastic compression for DVT-related edema. Elastic stockings/bandages are commonly mixed up with the non-stretch, inelastic compression bandages that are indicated for edema management.
Elastic compression can have very detrimental effects on the limb to which it is applied, such as reducing circulation, impairing lymphatic function, and if they gather and bunch up (as is common),even impairing neurological function and causing pressure wounds.
Strong, inelastic compression is indicated for edema management, especially in those with DVT related swelling. This can be a bandage complex using inelastic, woven materials, or use of an adjustable , inelastic garment.
But what about Manual Drainage?
As the goal for manual drainage is to open the lymphatic pathways and guide fluid back toward the body from peripheries, this should be avoided during the acute stage of a DVT.
The acute stage of DVT lasts up to 28 days, when the clot has formed but has not yet hardened/attached itself to the walls of the vessels. During this stage the thrombus can be more easily targeted by clot-busting agents, and Manual Lymphatic Drainage should be avoided during this period.
After this period, the DVT may be in the chronic stage. Here, it has shrunk and attached itself to the vessel walls, constricting them and impairing circulation. Here, MLD will be extremely helpful to assist in bypassing or giving more support to the veins for circulation and edema reduction.
Skin care is a vital area to address. Persistent, chronic edema can result in some skin conditions that may require additional care, and your patient should be advised about the risk of these. Your patient should also be advised about the possibility of cellulitis, how to recognize it and what steps to take- as this is a common complication of those with edema.
Exercise will actually reduce the symptoms of acute DVT, and may help to reduce or prevent the occurrence of PTS with patients. Exercise combined with wearing non-elastic compression will also greatly reduce the edema and swelling experienced by your patients.
And of course, patient education throughout the entire journey is going to be incredibly important for your person to know why they are engaging in treatment, manage their risk factors, comply with therapy, and continue to improve.
If edema management is something that you’re interested in, we’ve got more where that came from! Check out some of our other edema-related blog articles here:
- 7 Types of Swelling Therapists and Nurses Need to Know About!
- The Short and the Short of it: comparing low stretch bandages
- Have you seen these skin changes with your patients?
- Podcast- FOXcast PT: Edema Management with your Patients
Or join us at the next “Edema Management in In-patient Rehabilitation” course!
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