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The Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism—Executive Summary of an Evidence-Based Clinical Practice Guideline

Hillegass, Ellen PT, EdD, CCS, FAPTA; Puthoff, Michael PT, PhD, GCS; Frese, Ethel PT, DPT, MHS, CCS; Thigpen, Mary PT, PhD; Sobush, Dennis PT, MA, DPT, CCS, CEEAA; Auten, Beth MLIS, MA, AHIP

Cardiopulmonary Physical Therapy Journal: April 2016 - Volume 27 - Issue 2 - p 42–46
doi: 10.1097/CPT.0000000000000028
Executive Summary
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1Mercer University, Atlanta, GA

2St Ambrose University, Davenport, IA

3St Louis University, St Louis, MO

4Brenau University, Gainesville, GA

5Marquette University, Milwaukee, WI

The Cardiopulmonary Section, the Acute Care Section, and the American Physical Therapy Association provided funds to support the development and preparation of this document but had no influence on the content or the key action statements of this clinical practice guideline.

The authors declare no conflicts of interest.

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INTRODUCTION

Venous thromboembolism (VTE) is the formation of a blood clot in a deep vein that can lead to complications including deep-vein thrombus (DVT), a pulmonary embolism (PE), or post-thrombotic syndrome (PTS). Venous thromboembolism is a serious condition with an incidence of 10% to 30% of people dying within 1 month of diagnosis and half of those diagnosed with a DVT have long-term complications.1 Even with a standard course of anticoagulant therapy, one-third of individuals will experience another VTE within 10 years.1 For those who survive a VTE, the quality of life can be decreased because of the need for long-term anticoagulation to prevent another VTE.2

No matter the practice setting, physical therapists work with patients who are at risk for and/or have a history of VTE. Additionally, physical therapists are routinely tasked with mobilizing patients immediately after diagnosis of a VTE. Because of the seriousness of VTE, the frequency with which physical therapists encounter patients with a suspected or confirmed VTE, and the need to prevent future VTEs, the American Physical Therapy Association (APTA) in conjunction with the Cardiovascular & Pulmonary and Acute Care Sections of the APTA supported the development of this clinical practice guideline (CPG). This guideline is intended to assist all physical therapists in their decision-making processes when managing patients at risk for VTE or diagnosed with a lower-extremity deep-vein thrombosis (LE DVT).

In general, CPGs optimize the care of patients by building on the best evidence available while at the same time examining the benefits and risks of each care option.3 The VTE guideline development group followed a systematic process to write this CPG with the overall objective of providing physical therapists with the best evidence in preventing VTE, screening for an LE DVT, mobilization of patients with an LE DVT, and management of complications of the LE DVT. Specifically, the CPG:

  1. Discusses the role of physical therapists in identifying patients who are at high risk for VTE and actions that can be taken to decrease the risk of a first or recurring VTE.
  2. Provides physical therapists with specific tools to identify patients who may have an LE DVT and determine the likelihood of an LE DVT.
  3. Assists physical therapists in determining when mobilization is safe for a patient diagnosed with an LE DVT based on the treatment chosen by the interprofessional team.
  4. Describes interventions that will decrease diagnosis complications, such as PTS or another VTE.
  5. Creates a reference publication for health care providers, patients, families/caretakers, educators, policy makers, and payers on the best current practice of physical therapy management of patients at risk for VTE and diagnosed with an LE DVT.
  6. Identifies areas of research that are needed to improve the evidence base for physical therapy management of patients at risk for or diagnosed with VTE.

This CPG can be applied to adult patients across all practice settings but does not address nor apply to those who are pregnant or to children. Additionally, this guideline does not discuss the management of PE, upper extremity DVT or chronic thromboembolism pulmonary hypertension. Although primarily written for physical therapists, other health care professionals should find this CPG helpful in their management of patients who are at risk for or have a diagnosed VTE.

Fourteen key action statements were written to guide the physical therapist in decision-making based on a thorough review of the literature and CPGs, and the evidence supporting each action statement was rated with the strength of statement also provided. The 14 action statements are listed in Table 1. Clinical practice algorithms (Fig. 1–3) based on the key action statements were developed that can assist with clinical decision-making. Physical therapists along with other members of the health care team should work to implement these key action statements to decrease the incidence of VTE, improve the diagnosis and acute management of an LE DVT, and reduce the long-term complications of LE DVTs.

TABLE 1-a

TABLE 1-a

TABLE 1-b

TABLE 1-b

Fig. 1

Fig. 1

Fig. 2

Fig. 2

Fig. 3

Fig. 3

For full details on the guideline, see Physical Therapy Journal (available online at http://ptjournal.apta.org/content/96/2/143.full and in the February 2016 print issue).

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CONCLUSION

The major findings of this CPG are the following:

  1. Physical therapists should play a large role in identifying patients who are at high risk for VTE. Once these individuals are identified, preventive measures, such as referral for medication, initiation of activity/mobilization, mechanical compression, and education, should be implemented to decrease the risk of a first or reoccurring VTE.
  2. Physical therapists should be aware of the signs and symptoms of an LE DVT. When signs and symptoms are present, the likelihood of an LE DVT should be determined through the Wells' criteria for LE DVTs and the results should be shared with the interprofessional team to consider treatment options.
  3. In patients with a diagnosed LE DVT, once therapeutic levels of a medication or an acceptable time period has been reached after administration, mobilization should begin. Although there are risks associated with mobilization, the risk of inactivity is greater.
  4. Complications after an LE DVT can continue for years or even a lifetime. Physical therapists can help decrease these complications through education, mechanical compression, and exercise.
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REFERENCES

1. Beckman MG, Hooper WC, Critchley SE, et al.. Venous thromboembolism: a public health concern. Am J Prev Med. 2010;38:S495–S501.
2. Kahn SR, Ducruet T, Lamping DL, et al.. Prospective evaluation of health-related quality of life in patients with deep venous thrombosis. Arch Intern Med. 2005;165:1173–1178.
3. Committee on Standards for Developing Trustworthy Clinical Practice Guidelines. Clinical practice guidelines we can trust. Washington, DC: The National Academies Press; 2011.
© 2016 Cardiovascular and Pulmonary Section, APTA