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Wiley Journals Collection of journals in the sciences and social sciences. Acceptable Use of Library Resources J. Although anticoagulants are often referred to as blood thinners, they do not actually thin the blood. This class of drugs works by altering certain chemicals in the blood necessary for clotting to occur. Consequently, blood clots are less likely to form in the veins or arteries, and yet continue to form where needed.

Although anticoagulants do not break down clots that have already formed, they do allow the body's natural clot lysis mechanisms to work normally to break down clots that have formed. Anticoagulant therapy will help to stop an existing clot from getting larger and prevent any new clots from forming. In addition, LMWH has been shown to stabilize an existing clot and resolve symptoms through the drug's anti-inflammatory properties, making a clot less likely to migrate as an embolus.

A patient diagnosed with an LE DVT is at risk of developing a PE; therefore, mobility is contraindicated until intervention is initiated to reduce the chance of emboli traveling to the lungs. Therefore, prior to initiating mobility out of bed, a physical therapist should review all medications the patient has been prescribed and verify that the patient is taking an anticoagulant.

The physical therapist should next consult with the medical team regarding appropriateness of mobility. Although physical therapists do not play a role in recommending the anticoagulant of choice, they should identify which anticoagulant the patient has been prescribed and date and time of the first dose.

This approach will assist the physical therapist in determining when the patient has reached a therapeutic dose, and consequently, when mobility may be initiated safely. Concomitant Coumadin use may be started and provided for 3 days, with subsequent international normalized ratio INR values being determined. Most individuals will continue with their initial anticoagulant LMWH or fondaparinux for 3 to 6 months for the first episode of diagnosed thrombosis.

If Coumadin is given concomitantly, they will likely be removed from the initial anticoagulant and continued on Coumadin for 3 to 6 months.

However, evidence does not support the use of anti-Xa assay levels for predicting thrombosis and bleeding risk. Due to the fact that LMWH is excreted primarily by the kidneys, increased bleeding complications have been reported when LMWH is used in patients with renal insufficiency and other populations. Therefore, precautions for bruising and bleeding with physical therapy interventions should be taken when LMWH is used in patients with kidney injury or dysfunction, patients in extreme weight ranges, patients who are pregnant, and neonates and infants.

Unfractionated heparin is indicated for individuals with high bleeding risk eTable or renal disease. Unfractionated heparin is often prescribed and dosed to achieve therapeutic levels quickly. Lower speeds of infusion are usually given in acute coronary syndromes, whereas higher speeds of infusion are given with VTE.

Several institutions have transitioned from monitoring heparin with anti-factor Xa levels instead of activated partial thromboplastin time aPTT due to influencing factors that can alter aPTT levels. Coumadin is usually not the first medication choice for anticoagulation due to the length of time to achieve peak therapeutic levels. Mobility decisions with an individual receiving Coumadin are based on the initial anticoagulant and not Coumadin.

Concern regarding exercise and out-of-bed activity should be raised for elevated INRs greater than 4. When the INR is greater than 6. New oral anticoagulant drugs direct thrombin inhibitors and direct factor Xa inhibitors are growing in popularity due to their ease of use no laboratory monitoring, no adverse dietary or other drug interactions and their rapid time to peak therapeutic levels.

In addition, there appears to be less risk of cerebral hemorrhage, as occurs in vitamin K antagonists. The new oral anticoagulant drugs are recommended by the American Academy of Orthopaedic Surgeons for hip and knee arthroplasty but have not been tested or recommended for individuals who have cancer, are undergoing treatment for cancer, or are pregnant.

However, reconstructed recombinant factor Xa or activated charcoal have both been proposed as antidotes. With all anticoagulants there is a risk of bleeding. Therefore, in addition to the risk of VTE, physical therapists should be aware of and assess for risk of bleeding in all patients. Risk, Harm, Cost: Risks associated with use of anticoagulants include increased risk of bleeding. If an anticoagulant is not at a therapeutic level, there may be an increased risk of PE with mobilization.

Value Judgments: The evidence for mobility to prevent VTE is strong, although the evidence on when to initiate mobility may not be as strong and is based on the patient achieving the therapeutic level of the anticoagulant. Physical therapists should mobilize patients as soon as possible after diagnosis of VTE as long as the risk of PE is decreased. Achieving the therapeutic level of the anticoagulant has been shown to diminish the risk of developing a PE.

Intentional Vagueness: Specific anticoagulants or their therapeutic levels are not recommended. Instead, evidence-based guidelines and algorithms have been provided for guidance.

Role of Patient Preference: Patients should be aware of the anticoagulation they are prescribed and the effect that the anticoagulant will have on their lifestyle eg, amount of medical monitoring, risk of bleeding, foods to avoid, risk of brain bleed. In addition, patients should be informed regarding the risk of immobility in developing further VTE and the benefit of mobility.

Exclusions: The risk of bleeding is present when anyone takes anticoagulants. However, patients with HIT, a history of HIT, recent bleeding events, or increased risk of bleeding should be prescribed treatment other than anticoagulation, including mechanical compression or intravenous filters. Patients who have a documented LE DVT and have reached therapeutic levels of the prescribed anticoagulant should be mobilized out of bed and ambulate to prevent venous stasis.

In doing so, deconditioning is minimized, length of hospital stay may be shortened, and other adverse effects of prolonged bed rest eg, decubiti can be avoided. A common concern for mobilizing a patient with an LE DVT is that the clot will dislodge and embolize to the lungs, causing a potentially fatal PE. However, early ambulation has been shown to lead to no greater risk of PE than bed rest for people with a diagnosed LE DVT who have been treated with anticoagulants.

A meta-analysis showed the absence of a higher risk of new PE or other adverse clinical events when individuals were ambulated instead of kept on bed rest. In , the ACCP published guidelines on antithrombotic therapy and prevention of thrombosis provided a moderate strength recommendation that patients with an acute LE DVT should receive early ambulation over initial bed rest because of the potential to decrease PTS and improve quality of life.

Early mobilization has added benefits. Based on the evidence that exists on time to peak therapeutic levels of the anticoagulants refer to eTable , expert consensus exists to recommend early ambulation of individuals with an LE DVT who are receiving anticoagulation and have reached their peak therapeutic levels based on the specific anticoagulation medication they are prescribed.

Intentional Vagueness: Types of mechanical compression were not recommended. Role of Patient Preference: Ease of use, comfort level, and ability to operate mechanical compression equipment properly should be discussed with patients and their families or caregivers. Exclusions: Patients who have severe peripheral neuropathy, arterial insufficiency, dermatologic diseases, or lesions may have contraindications to selective mechanical compression modes.

Systematic reviews pertaining to the adjuvant use of mechanical compression garments for patients who are anticoagulated and have acute VTE eg, LE DVT while on bed rest or with early ambulation compared with controls provide supportive evidence for their use.

Two additional RCTs 96 , 97 on patients who were anticoagulated and had acute LE DVT combined early ambulation with the wearing of either inelastic rigid stockings above the knee ie, zinc plaster Unna boots providing 50 mm Hg of interface pressure at the ankle or thigh-length elastic stockings ie, providing an interface pressure of 30 mm Hg at the ankle compared with control patients on bed rest.

The combination of GCS with ambulation resulted in a faster resolution of pain and swelling and an increased quality-of-life outcome measure. In summary, the evidence to support mechanical compression methods as effective treatment interventions for secondary VTE prevention varies according to patient VTE risk profile, acute eg, hemodynamic stability versus chronic eg, PTS concern status, degree of signs eg, swelling and symptoms eg, pain , and consideration for potentially harmful outcomes eg, skin lesions.

Whether used adjunctively along with anticoagulants, alone as in patients when anticoagulant use is contraindicated, or in combination eg, ambulation plus GCS with or without anticoagulation, mechanical compression use has mostly been favorable. Controversy persists, however, regarding whether to support the routine use of mechanical compression eg, GCS for LE DVT management and secondary prevention.

Regardless of whether the mode of mechanical compression is by GCS or another means eg, IPC , the optimal mechanical compression treatment strategy has yet to be identified. Physical therapists should mobilize patients after IVC filter placement once they are hemodynamically stable and there is no bleeding at the puncture site. Benefits: Decreased risk of PE reduced in-hospital fatality rate in patients who are stable and those who are unstable. Value Judgments: An IVC filter is valuable for patients at high risk who are unable to be given anticoagulants.

Exclusions: Patients with contraindications to IVC filter placement. Inferior vena cava filter placement is a type of percutaneous endovascular intervention for venous thromboembolic disease and is usually performed by an interventional radiologist. Venous access is via the right internal jugular or right femoral veins. The best placement location for the IVC filter to prevent lower extremity and pelvic VTE is just inferior to the renal veins. Following placement of an IVC filter, the patient should be mobilized once he or she is hemodynamically stable and there is no bleeding at the puncture site.

Benefits: Mobility has demonstrated a decreased risk of VTE. Value Judgments: As movement specialists, physical therapists recommend mobilization over bed rest due to the documented benefits of early mobilization. Intentional Vagueness: Specific guidelines are not provided because it is rare that a patient will not have anticoagulants prescribed or an IVC filter in this country.

Each patient should be considered individually. Role of Patient Preferences: Patients should be informed of the risks and benefits of bed rest and inactivity and of mobilization. The patients may have contraindications for receiving anticoagulant medications or they do not meet the criteria for an IVC eg, in palliative care or hospice care.

In these situations, a consult with the primary physician or medical team should guide the decision to mobilize the patient. Continuing to remain on bed rest will only increase the risk of additional VTE and other adverse effects of immobilization. At some point, the patient needs to return to daily activities, and it might be appropriate to begin mobilization even though an untreated LE DVT is present. It may be wise to wait until anticoagulation can begin. The physical therapist needs to discuss all of these factors with the interprofessional team and the patient when making a clinical judgment about mobilization.

Although a physician may order physical therapy to increase the physical activity level of a patient, it is the physical therapist's clinical decision whether to mobilize the patient based on the available information about the patient's LE DVT and risk status. Value Judgments: Fall prevention is a prudent step in managing patients who are at increased risk for bleeding.

A major bleed event is a possible complication in patients taking an anticoagulant medication. Use of oral anticoagulants increases the risk of intracerebral bleeds by 7 to 10 times. Age is considered a major risk factor for falls. People 75 years of age and older have the highest rate of falls, and 1 in 3 individuals over the age of 65 years fall each year. If a fall or unsteadiness has been reported, further assessment of strength, balance, and other risk factors should be completed. In general, the population of individuals on anticoagulants is made up of older adults who would benefit from fall risk screening.

Risk, Harm, Cost: Improper fit can lead to skin irritation, ulceration, and interruption of blood flow. Intentional Vagueness: The specific types of mechanical compression were not recommended. Role of Patient Preference: Ease of use, comfort level, and ability to operate mechanical compression equipment properly should be discussed with the patient and caregiver. As the thrombus initiates an inflammatory response, venous valves may become damaged during this process of thrombus resolution, which is often incomplete over time.

The damaged venous valves cause valvular reflux, and as remodeling of the vein wall occurs, they may become stiff and contribute to increased outflow resistance, which increases blood pressure in the veins. This increase in transluminal pressure causes leakage into the interstitial space, leading to edema and skin changes. Microcirculation and blood supply to the leg muscles become compromised, which can lead to venous ulcerations in the more severe instances of PTS.

Once PTS is suspected, a specific and sensitive rating instrument referred to as the Villalta scale can be used to grade the severity of PTS. A meta-analysis conducted on 5 RCTs determined that venous compression stockings or compression bandages are effective in reducing PTS in patients.

Thus, GCS reduces the severity of PTS, although there was a wide variation in the type of stockings used, time interval from diagnosis to application of stockings, and duration of treatment. Findings from the first review based on 2 RCTs included favorable trends using higher pressures of IPC over that of lower pressures and that there was not enough evidence to support the use of elastic GCS 30—40 mm Hg pressures at the ankle versus placebo stockings in patients with mild-to-moderate PTS severity.

No venous ulceration was observed in either group, with symptom relief significantly in favor of compression treatment during the first year but not thereafter. The conclusion reached was that prolonged use of GCS after proximal DVT significantly reduces symptoms and signs of postthrombotic skin changes. In the evidence-based guideline by the Finnish Medical Society Duodecim, immediate bandaging for compression during the acute phase of DVT up to the groin, if needed is recommended in circular rather than figure-eight turns.

Pooled results from 4 RCTs in another systematic review in patients with confirmed proximal LE DVT used compression bandaging inelastic or elastic , with or without early ambulation, as an intervention for PTS. The lack of uniformity in reporting standards, such as the timing, duration, and degree of compression interface pressure, among other descriptors, makes it difficult for meaningful comparisons among studies.

This concern has been raised by more than one investigative group. In summary, mechanical compression eg, with IPC or compression bandaging, activation of the calf muscle pump , with or without ambulation, is the cornerstone in the treatment of PTS. The intervention strategy is primarily focused on decreasing venous pressure in the involved lower extremity, enhancement of the microcirculation, and reduction of the edema.

The efficacy in treating PTS after confirmed acute LE DVT and its development during the subacute period or as a debilitating chronic condition thereafter do favor the early application and prolonged use of mechanical compression. The lack in uniformity of the methods and prescriptive protocols followed in the use of mechanical compression lends itself to controversy. Nevertheless, the preponderance of quality evidence does warrant a strong recommendation.

Benefit: Decreasing the incidence of LE DVT recurrence and minimizing the severity of PTS signs and symptoms in order to enhance functional mobility and a person's quality of life experience. Risk, Harm, Cost: Improper fit of mechanical compression can lead to skin irritation, ulceration, and interruption of blood flow. Intentional Vagueness: No specific types of mechanical compression were recommended.

Role of Patient Preference: Ease of use, comfort level, and ability to operate mechanical compression equipment properly. Exclusions: Patients who have severe peripheral neuropathy, arterial insufficiency, decompensated heart failure, dermatologic diseases, or lesions may have contraindications to selective mechanical compression modes. The ability of a clinician to accurately predict level of risk for recurrent VTE eg, low versus high has been investigated using the Pulmonary Embolism Severity Index PESI clinical prediction rule and found to be of merit.

The ability to distinguish or recognize that PTS is present is important for the clinician to determine. Postthrombotic syndrome is defined as a combination of clinical signs and symptoms occurring after an 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 ie, 11 and symptoms ie, 12 used between them.

For example, mechanical compression aims to manage factors responsible for the pathogenesis of VTE ie, Virchow's triad of hypercoagulopathy, venous stasis, and endothelial damage by reducing swelling, accelerating venous return, and improving muscle pump function. In summary, patients who have a prior history of VTE are at high risk for recurrent VTE, especially when they are immobilized or are of advanced age. 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. The major findings of this CPG are the following: Physical therapists should play a large role in identifying patients who are at high risk for a VTE.

Once these individuals are identified, preventive measures such as referral for medication, initiation of activity or mobilization, mechanical compression, and education should be implemented to decrease the risk of a first or reoccurring VTE. When signs and symptoms are present, the likelihood of an LE DVT should be determined through the Wells criteria for LE DVT, and results should be shared with the interprofessional team to consider treatment options.

In patients with a diagnosed LE DVT, once a medication's therapeutic levels 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. Physical therapists can help decrease these complications through education, mechanical compression, and exercise.

Creation of checklist and sample evaluation forms incorporating the recommendations of the CPG. In order to implement these recommendations, physical therapists and the entire health care team should take the following steps: Integrate key action statements within this article into clinical practice.

Form interprofessional teams that address VTE and ensure all providers know about and then implement the recommendations in this CPG. This recommendation may be done through embedding risk assessment into standardized examination forms or working with referral sources to encourage early mobilization after diagnoses of VTE.

As demonstrated in the areas of early mobilization in the intensive care unit and diabetes and chronic pain management, interprofessional teams are effective when attempting to change the culture of an organization to improve patient outcomes. Physical therapists need to seek out membership in these interprofessional committees and serve as clinical champions in the areas of VTE prevention and management.

As movement specialists, physical therapists understand the importance of mobilization and activity and have the ability to modify interventions based on medical history and patient problems. Physical therapists can add greatly to the scope and depth of these teams. Although researchers have addressed multiple aspects of VTE management, there are still many unanswered questions.

A few future research questions that are specific to the physical therapy management are listed below: Does aggressive screening for LE DVT lead to a decline in the incidence of PE? Does the implementation of guidelines for mobilization of patients with LE DVT lead to earlier mobilization and improved patient outcomes? What are guidelines for mobilization of individuals with a hemodynamically unstable PE?

The authors would like to thank the following people for their participation in the development of these guidelines: Christa Stout, our fabulous guideline assistant, and St Ambrose University graduate assistant Catherine Berger. Patient Reviewer: Elizabeth Olszewski. Feuling, David Schweisberger, and Karen Collins. The authors declare no conflicts of interest. This guideline is scheduled to be updated 5 years from date of publication.

Each of the panel members was asked to disclose any existing or potential conflicts of interest, including financial relationships with pharmaceutical, medical device, or biotechnology companies, prior to being included in the panel.

The panel declared no conflicts of interest. This CPG is not intended as the sole source of guidance in managing patients at risk for or diagnosed with venous thromboembolism. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. This CPG is not intended to replace clinical judgment or establish a protocol for all individuals with this condition and may not provide the only appropriate approach to managing the problem.

This CPG may be used to develop policy or suggest policy changes, or it may provide discussion about current policy. However, it is up to individual facilities to determine whether they want to adopt these CPG key action statement recommendations in place of their existing policies or protocols.

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