Show
A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the leg, but can occur in the veins of the arms and the mesenteric and cerebral veins. It is a common disorder and belongs to the venous thromboembolism disorders. DVTs represent the third most common cause of death from cardiovascular disease after heart attacks and stroke, and account for most cases of pulmonary embolism. Only through early diagnosis and treatment can the morbidity be reduced[1].[2] For those who do develop a DVT and survive, post-thrombotic phlebitis is a lifelong sequela, which has no ideal treatment[2]. Epidemiology[edit | edit source]
Pathology[edit | edit source]The majority of lower extremity DVTs develop in the veins of the calf, being the peroneal veins, posterior tibial veins and the veins of the gastrocnemius and soleus muscles[3]. The following video provides a visual representation of DVT pathology: Risk Factors[edit | edit source]Following are the risk factors and are considered as causes of deep venous thrombosis:
Increased Risk of Coagulation
Constitutional Factors
Clinical Presentation[edit | edit source]History
Physical Examination
Clinical Prediction Rule (CPR): Well's Criteria[edit | edit source]Well's Criteria is the most commonly used tool to screen for DVT risk:[1]
In the original scale, the total score for all items is tallied and the probability of the patient having a DVT is as follows: 0= low probability, 1-2 points= moderate probability,and ≥ 3 points= high probability.[4] An updated version simplifies the scoring process into two categories: < 2 points= DVT unlikely, ≥ 2 points= DVT likely.[5] Well's Criteria is a valid tool for assessing DVT risk in outpatient[6][7] and trauma[8] patients. It is less useful for stratifying risk in cancer patients[7] and hospitalized patients as a whole.[9] It cannot be used to screen for UE DVT.[10] Clinical Tests[edit | edit source]The clinical diagnosis of DVT is unreliable. However, in combination with valid screening tools, clinical examination can justify the need for diagnostic testing.
Homan's Sign Diagnostic Procedures[edit | edit source]As per the NICE guidelines following investigations are done:
D-Dimer Testing
Management / Interventions[edit | edit source]Primary Prevention A combination of mechanical and pharmacological measures can be used to prevent DVT. Mechanical prophylaxis involves the use of graduated compression stockings (GCS), intermittent pneumatic compression (IPC) and venous foot pumps to improve blood flow in the deep veins of the leg. Common agents for pharmacological prophylaxis include Warfarin, subcutaneous unfractionated heparin (UFH) and low-molecular-weight heparins (LMWH).[12] DVT prevention is most effective when both methods are used simultaneously.[1] In medical and surgical patients ambulation and exercises involving ankle dorsiflexion are encouraged to further minimize venous stasis.[1] Medical Management Treatment of DVT aims to prevent pulmonary embolism, reduce morbidity, and prevent or minimize the risk of developing post-thrombotic syndrome. The cornerstone of treatment is anticoagulation. NICE guidelines only recommend treating proximal DVT (not distal) and those with pulmonary emboli. In each patient, the risks of anticoagulation need to be weighed against the benefits Secondary Prevention Early Mobilization
Graduated Compression Stockings
Implications for Physical Therapy Practice[edit | edit source]Physical therapists work with patients at risk for and with diagnosed DVT across the continuum of care. For this reason, the American Physical Therapy Association (APTA) has developed clinical practice guidelines (CPG)[16] to facilitate decision making in the prevention and management of LE DVT in adults. The following table outlines the 5 responsibilities of physical therapists (PTs) with actionable recommendations:
Resources Presentations[edit | edit source]
|