Deep Vein Thrombosis: Difference between revisions

No edit summary
(adding a video)
 
(40 intermediate revisions by 7 users not shown)
Line 2: Line 2:
'''Original Editor '''- [[User:Jennifer Self|Jennifer Self]]  
'''Original Editor '''- [[User:Jennifer Self|Jennifer Self]]  


'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}    
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}  
</div>[[Image:Leg veins.png|right|100px]]
</div>  
== Introduction ==
[[Image:DVT.jpg|thumb|150px|DVT: R leg with swelling and redness]]
A deep-vein [[thrombosis]] (DVT) is a blood clot that forms within the deep [[Cardiovascular System|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|cardiovascular disease]] after [[Acute Coronary Syndrome|heart attacks]] and [[stroke]], and account for most cases of [[Pulmonary Embolism|pulmonary embolism.]] Only through early diagnosis and treatment can the morbidity be reduced<ref name=":1">Kesieme E, Kesieme C, Jebbin N, Irekpita E, Dongo A. Deep vein thrombosis: a clinical review. J Blood Med 2011; 2:59–69.</ref>.<ref name=":9">Waheed SM, Kudaravalli P, Hotwagner DT. [https://www.ncbi.nlm.nih.gov/books/NBK507708/ Deep vein thrombosis (DVT)]. StatPearls [Internet]. 2020 Aug 10. Available from:https://www.ncbi.nlm.nih.gov/books/NBK507708/ (last accessed 25.10.2020)</ref> For those who do develop a DVT and survive, '''post-thrombotic phlebitis''' is a lifelong sequela, which has no ideal treatment<ref name=":9" />.


== Clinically Relevant Anatomy ==
== Epidemiology ==
Deep Vein Thrombosis (DVT) is when one or more blood clots form in a deep vein of the body. The most common site for DVT is the lower limbs.<ref name=":1">Kesieme E, Kesieme C, Jebbin N, Irekpita E, Dongo A. Deep vein thrombosis: a clinical review. J Blood Med 2011; 2:59–69.</ref> Proximal DVTs of the lower extremity (LE) involve the popliteal and/or thigh veins (femoral vein, external iliac vein, deep vein of the thigh), while distal DVTs encompass those that develop in the calf.


DVTs in the upper extremity (UE) are less common (4-10% of all cases).<ref name=":2">Heil J, Miesbach W, Vogl T, Bechstein WO, Reinisch A. Deep vein thrombosis of the upper extremity: A systematic review. Dtsch Arztebl Int 2017; 114(14): 244–249</ref> The deep veins of the upper extremity include the jugular, brachiocephalic, subclavian, and axillary veins proximally and the brachial, ulnar, and radial veins distally. In the upper extremity, the subclavian, jugular and axillary veins are the primary vessels in which DVTs form.<ref name=":2" /><ref name=":3">Joffe H, Kucher N, Tapson V, Goldhaber S. Upper-extremity deep vein thrombosis: a prospective registry of 593 patients. Circulation 2004; 110: 1605-1611</ref>
* 1.6 new cases per 1000 per year
* 2.5-5% of the population is affected
* >50% have long terms symptoms of post-thrombotic syndrome
* 6% of DVT patients report eventual venous ulcers (0.1% general population)<ref name=":0">Radiopedia DVT Available:https://radiopaedia.org/articles/deep-vein-thrombosis (accessed 19.7.2022)</ref>


== Pathological Process  ==
== Pathology ==
 
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<ref name=":0" />.
Thrombi develop as a result of hypercoagulation and stasis around venous valve sinuses. The majority of deep vein thrombi start in the calf.<ref name=":4">Kearon C. Natural history of venous thromboembolism. Seminars in Vascular Medicine 2001; 01(1): 027-038</ref> These clots are firm and are mostly made up of fibrin and red blood cells<ref name=":1" /> ([http://www.topnews.in/health/files/Deep-Vein-Thrombosis.jpg see the image of a DVT here]). On autopsy, the majority are attached to venous walls.<ref name=":1" />    
 
Within 72 hours, an estimated 50% of intra-operative calf DVTs resolve on their own.<ref name=":4" /> About 1 in 6 of these extend into the proximal veins of the leg,<ref name=":4" /> causing venous obstruction and damage to affected valves. A subset of proximal DVTs become mobile and progress to pulmonary embolism, a potentially fatal condition. Progression to [https://emedicine.medscape.com/article/300901-overview pulmonary embolism] is more common in LE than UE DVTs.<ref name=":3" />   


The following video provides a visual representation of DVT pathology:
The following video provides a visual representation of DVT pathology:
Line 20: Line 22:


== Risk Factors ==
== Risk Factors ==
Various risk factors play into the formation of DVTs. In adults, blood clotting disorders are associated with spontaneous formation.<ref name=":1" /> Several other clinical factors augment patient risk as well:<ref name=":1" />
[[File:DVT sites.jpeg|thumb|434x434px|Mapping the at-risk area for deep vein thrombosis ]]
{| class="wikitable"
Following are the risk factors and are considered as causes of deep venous thrombosis:
!Clinical Condition
*Reduced [[Blood Physiology|blood]] flow: Immobility (bed rest, general [[Surgery and General Anaesthetic|anesthesia]], operations or surgery<ref>Solis G, Saxby T. Incidence of DVT following surgery of the foot and ankle. Foot & ankle international. 2002 May;23(5):411-4.</ref>, long flights)
!Medical Interventions
* Mechanical compression or functional impairment which reduces flow in the veins (eg [[Oncology|neoplasm]], pregnancy, [[Varicose Veins|varicose veins]])
!Environment
* Mechanical injury to the vein eg Trauma, surgery, peripherally inserted venous catheters, previous DVT, intravenous drug abuse.
|-
* Increased blood viscosity eg thrombocytosis, [[dehydration]]
|
* Anatomic variations in venous anatomy can contribute to thrombosis.
* Acute Infection
Increased Risk of Coagulation
* Cancer
* Genetic deficiencies: Anticoagulation proteins C and S, antithrombin III deficiency, factor V Leiden mutation
* Stroke or paralysis
* Acquired: eg Cancer, [[sepsis]], [[Myocardial Infarction|myocardial infarction]], [[Heart Failure|heart failure]], vasculitis, [[Systemic Lupus Erythematosus|systemic lupus erythematosus]], [[Irritable Bowel Syndrome|inflammatory bowel disease]], [[Chronic Kidney Disease|nephrotic]] syndrome, burns, oral estrogens, [[Smoking Cessation and Brief Intervention|smoking]], [[Blood Pressure|hypertension]], [[diabetes]]
* Previous VTE*
Constitutional Factors
* Congestive heart failure
* [[Obesity]], pregnancy, [[Older People - An Introduction|Increasing age]], surgery, and cancer.
* Pregnancy or peurperium
== Clinical Presentation ==
* [https://www.physio-pedia.com/Dehydration Dehydration]
[[File:Varices de la safena magna.jpg|alt=|thumb|Varicose veins of the great saphenous vein]]History
* Varicose veins
# Pain (50% of patients)
* Nephrotic syndrome
# Redness
* Rheumatological disease
# Swelling (70% of patients)
* Acute inflammatory bowel disease
Physical Examination
|
# Limb [[Oedema Assessment|edema]] may be unilateral or bilateral if the thrombus is extending to pelvic veins
* Hormonal treatment
# Red and hot [[skin]], with dilated veins
* Chemotherapy
# Tenderness<ref name=":9" />
* Birth control pills
* Recent major surgery
|
* Prolonged immobility
* Long air travel
|}
[*VTE= venous thromboembolism]


The UE has its own set of additional risk factors:<ref name=":2" /><ref name=":3" />
== Clinical Prediction Rule (CPR): Well's Criteria  ==
* Intravenous catheters
* Pacemaker cables
* Anatomical anomalies (ex. shoulder girdle syndrome, clavicular fractures, Paget–von Schroetter syndrome)
Risk factors more prominent in children include [https://www.physio-pedia.com/Sickle_Cell_Anemia sickle cell] disease, severe infection, antiphospholipid syndromes and trauma.<ref>Gertziafas GT. Risk factors for venous embolism in children. Int Angiol 2004;2 3(3):195–205</ref>
== Clinical Presentation ==
[[Image:DVT.jpg|thumb|150px|DVT in the right leg with swelling and redness]]
The clinical presentation of individuals with DVT is inconsistent, as many patients are asymptomatic. Those with symptoms may demonstrate the following features in the affected extremity:<ref name=":1" />
* Discoloration
* Pain/discomfort
* Warmth
* Swelling
* Tenderness
== Clinical Prediction Rule (CDR): Well's Criteria  ==


Well's Criteria is the most commonly used tool to screen for DVT risk:<ref name=":1" />
Well's Criteria is the most commonly used tool to screen for DVT risk:<ref name=":1" />
Line 75: Line 57:
| +1
| +1
|-
|-
|Recently bedridden for > 3 days or major surgery within 4 weeks
|Recently bed ridden for > 3 days or major surgery within 4 weeks<ref>Song K, Yao Y, Rong Z, Shen Y, Zheng M, Jiang Q. The preoperative incidence of deep vein thrombosis (DVT) and its correlation with postoperative DVT in patients undergoing elective surgery for femoral neck fractures. Archives of orthopaedic and trauma surgery. 2016 Oct;136:1459-64.</ref>
| +1
| +1
|-
|-
Line 96: Line 78:
| -2
| -2
|}
|}
In the original scale, the total score for all items is tallied and the probability of the patients having a DVT are as follows: 0= low probability, 1-2 points= moderate probability,and ≥ 3 points= high probability.<ref>Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C, Weitz J, D'Ovidio R, Cogo A, Prandoni P.  Accuracy of clinical assessment of deep-vein thrombosis. Lancet 1995; 345(8961):1326-1330</ref> The updated simplifies the scoring process into two categories: ≤ 2 points= DVT unlikely, ≥ 2 points= DVT likely.<ref>Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C, Dreyer J, Kovacs G, Mitchell M, Lewandowski B, Kovacs MJ. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med 2003; 349:1227–1235</ref>
'''In the original scale:'''


Well's Criteria is a valid tool for assessing DVT risk in outpatient<ref>Wells  PS, Anderson  DR, Bormanis  J, Guy F, Mitchell M, Gray L, Clement C, Robinson KS, Lewandowski B. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet 1997; 350(9094):1795-1798</ref><ref name=":5">Geersing  GJ, Zuithoff  NPA, Kearon  C, Anderson DR, Cate-Hoek T, Elf JL, Bates SM, Hoes AW, Kraaijenhagen RA, Oudega R, Schutgens RE, Stevens SM, Woller SC, Wells PS, Moons KG. Exclusion of deep vein thrombosis using the Wells rule in clinically important subgroups: individual patient data meta-analysis. BMJ 2014; 348:g1340</ref> and trauma<ref>Modi S, Deisler R, Gozel K, Reicks P, Irwin E, Brunsvold M, Banton K, Beilman GJ. Wells criteria for DVT is a reliable clinical tool to assess the risk of deep venous thrombosis in trauma patients. World J Emerg Surg. 2016; 11: 24</ref> patients. It is less useful for stratifying risk in cancer patients<ref name=":5" /> and hospitalized patients as a whole.<ref>Silveira PC, Ip IK, Goldhaber SZ, Piazza G, Benson CB, Khorasani R. Performance of Wells Score for Deep Vein Thrombosis in the Inpatient Setting. JAMA Intern Med 2015; 175(7):1112-7</ref> It cannot be used to screen patients for upper extremity DVT.<ref name=":2" />
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.<ref>Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C, Weitz J, D'Ovidio R, Cogo A, Prandoni P.  Accuracy of clinical assessment of deep-vein thrombosis. Lancet 1995; 345(8961):1326-1330</ref> An updated version simplifies the scoring process into two categories: < 2 points= DVT unlikely, ≥ 2 points= DVT likely.<ref>Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C, Dreyer J, Kovacs G, Mitchell M, Lewandowski B, Kovacs MJ. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med 2003; 349:1227–1235</ref>


== Clinical Tests/Examination  ==
'''Well's Criteria'''<ref>Modi S, Deisler R, Gozel K, Reicks P, Irwin E, Brunsvold M, Banton K, Beilman GJ. Wells criteria for DVT is a reliable clinical tool to assess the risk of deep venous thrombosis in trauma patients. World Journal of Emergency Surgery. 2016 Dec;11:1-6.</ref> is a valid tool for assessing DVT risk in outpatient<ref>Wells  PS, Anderson  DR, Bormanis  J, Guy F, Mitchell M, Gray L, Clement C, Robinson KS, Lewandowski B. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet 1997; 350(9094):1795-1798</ref><ref name=":5">Geersing  GJ, Zuithoff  NPA, Kearon  C, Anderson DR, Cate-Hoek T, Elf JL, Bates SM, Hoes AW, Kraaijenhagen RA, Oudega R, Schutgens RE, Stevens SM, Woller SC, Wells PS, Moons KG. Exclusion of deep vein thrombosis using the Wells rule in clinically important subgroups: individual patient data meta-analysis. BMJ 2014; 348:g1340</ref> and trauma<ref>Modi S, Deisler R, Gozel K, Reicks P, Irwin E, Brunsvold M, Banton K, Beilman GJ. Wells criteria for DVT is a reliable clinical tool to assess the risk of deep venous thrombosis in trauma patients. World J Emerg Surg. 2016; 11: 24</ref> patients. It is '''less useful''' for stratifying risk in cancer patients<ref name=":5" /> and hospitalized patients as a whole.<ref>Silveira PC, Ip IK, Goldhaber SZ, Piazza G, Benson CB, Khorasani R. Performance of Wells Score for Deep Vein Thrombosis in the Inpatient Setting. JAMA Intern Med 2015; 175(7):1112-7</ref> It cannot be used to screen for UE DVT.<ref name=":2">Heil J, Miesbach W, Vogl T, Bechstein WO, Reinisch A. Deep vein thrombosis of the upper extremity: A systematic review. Dtsch Arztebl Int 2017; 114(14): 244–249</ref>


The clinical diagnosis of DVT is unreliable. However, in combination with valid screening tools, clinical examination can justify the need for diagnostic testing.
== Clinical Tests ==
=== Observation and Palpation ===
[[File:Pitting edema.jpg|thumb|Pitting edema]]Clinical observation and palpation should focus on identifying the signs and symptoms described in the "Clinical Presentation" section of this article.
=== Homan's Sign ===
Homan's Sign has been used as an indicator for lower extremity DVT since the 1940s.<ref name=":6">Urbano F. Homans' Sign in the Diagnosis of Deep Venous Thrombosis. Hospital Physician 2001. 22-24</ref> The test is performed by forcefully dorsiflexing the ankle while the slightly knee flexed. Pain and tenderness in the calf is said to be indicative of lower extremity DVT. Despite its historical use, Homan's sign has no diagnostic value in the identification of LE DVT.<ref name=":6" />


== Diagnostic Testing ==
The clinical diagnosis of DVT is unreliable. However, in combination with valid screening tools, clinical examination can justify the need for diagnostic testing<ref>Scarvelis D, Wells PS. Diagnosis and treatment of deep-vein thrombosis. Cmaj. 2006 Oct 24;175(9):1087-92.</ref>.
Diagnostic testing is the only definitive way to diagnose DVT.<ref name=":1" />
* Focus on identifying the signs and symptoms described in the "Clinical Presentation" section of this article.
 
[[Homan's Sign Test|Homan's Sign]]
=== D-Dimer Testing  ===
 
A simple blood test of fibrin degradation. D-dimer levels in the blood are increased by any condition that produces fibrin; this testing has been found to be the most useful blood marker of fibrinolysis. The negative likelihood ratio is higher than 99%. This test is best used on outpatients with a low probability of proximal DVT, based on the use of the CDR by Wells &amp; colleagues.<ref name="Riddle">Riddle DL, Wells PS. Diagnosis of Lower-Extremity Deep Vein Thrombosis in Outpatients. Physical Therapy. 84 (8); 729-735.</ref><br>
 
=== Venous Ultrasound  ===
Venous ultrasound is considered to be the first-choice diagnostic test for patients with symptomatic DVT in the moderate to high probability groups.[DVT clinical review] The test is a safe, non-invasive and inexpensive. Depending on availability, patient characteristics and the location of the suspected DVT, compression ultrasound, duplex ultrasound or color Doppler imaging may be used.[DVT clinical review] The sensitivity and specificity of compression ultrasonography averages 95% for detection of proximal DVT.<ref name="Riddle" /><br>


== Diagnostic Procedures ==
[[Image:Venography.jpg|thumb|200px|Venography]]
[[Image:Venography.jpg|thumb|200px|Venography]]
=== Venography  ===
As per the NICE guidelines following investigations are done:
 
* D-dimers (very sensitive but not very specific)
This is considered the gold standard test for DVT.[DVT clinical review] The test is rarely used due to its invasive nature and availability of accurate, non-invasive options (D-dimer and venous ultrasound). The procedure involves an x-ray of the veins (venogram) taken after a special dye is injected into the bone marrow or veins.<ref name="Riddle" />
* Coagulation profile
* Proximal leg vein ultrasound, which when positive, indicates that the patient should be treated as having a DVT<ref name=":9" />
D-Dimer Testing
* D-dimer testing is a simple blood test of fibrin degradation. D-dimer levels are increased by any condition that produces fibrin, one of the primary components of deep vein thrombi. The negative likelihood ratio is higher than 99%. According to Wells and colleagues,<ref name="Riddle">Riddle DL, Wells PS. Diagnosis of Lower-Extremity Deep Vein Thrombosis in Outpatients. Physical Therapy. 84 (8); 729-735.</ref> the test is best used to rule out DVT in outpatients with a low probability of proximal DVT.<br>
== Management / Interventions  ==
== Management / Interventions  ==
'''Primary Prevention'''


=== Primary Prevention ===
A combination of '''mechanical''' and '''pharmacological''' measures can be used to prevent DVT<ref>Morillo R, Jiménez D, Aibar MÁ, Mastroiacovo D, Wells PS, Sampériz Á, De Sousa MS, Muriel A, Yusen RD, Monreal M, Decousus H. DVT management and outcome trends, 2001 to 2014. Chest. 2016 Aug 1;150(2):374-83.</ref>. 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).<ref name=":3">Joffe H, Kucher N, Tapson V, Goldhaber S. Upper-extremity deep vein thrombosis: a prospective registry of 593 patients. Circulation 2004; 110: 1605-1611</ref> DVT prevention is most effective when both methods are used simultaneously.<ref name=":1" /> In medical and surgical patients ambulation and exercises involving ankle dorsiflexion are encouraged to further minimize venous stasis.<ref name=":1" />
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).<ref name=":3" /> DVT prevention is most effective when both methods are used simultaneously.<ref name=":1" /> In medical and surgical patients ambulation and exercises involving ankle dorsiflexion are encouraged to further minimize venous stasis.<ref name=":1" />  
 
=== Medical Treatment ===


==== Anticoagulation ====
'''Medical Management'''
Anticoagulation is the usual treatment for DVT. Patients are generally initiated on a brief course (i.e., less than a week) of heparin treatment.<ref name=":0">Snow V, Qaseem A, Barry P, et al. (2007). "Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians". Ann. Intern. Med. 146 (3): 204–10.</ref> If heparin is contraindicated, fondaparinux (FDX) or direct or anticoagulants (DOAC) [ex. Xarelto, dabigatran, apixaban] may be used.<ref name=":1" /> Acute DVT treatment is followed by a maintenance course (typically 3-6 months) of warfarin or other Vitamin K inhibitors.<ref name=":1" /><ref name=":0" /> Variations in treatment may exist for patients with delayed removal of an intravenous catheter or an ongoing tumor disease in the case of UE DVT.<ref name=":2" />


==== Thrombolysis  ====
Treatment of DVT aims to prevent pulmonary embolism, reduce morbidity, and prevent or minimize the risk of developing post-thrombotic syndrome.


Although rarely indicated, thrombolytic therapy is used to treat an extensive clot.<ref name=":1" /> A meta-analysis of randomized controlled trials by the Cochrane Collaboration<ref>Watson L, Armon M (2004). "Thrombolysis for acute deep vein thrombosis". Cochrane Database Syst Rev: CD002783</ref> shows improved outcomes with thrombolysis, although there may be an increase in serious bleeding complications.
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


==== Inferior Vena Cava (IVC) Filter ====
'''Secondary Prevention'''[[File:Compression stockings.jpg|thumb|271x271px|Compression stockings.]]Early Mobilization
IVC filters may prevent pulmonary embolisation and is an option for patients with an absolute contraindication to anticoagulant treatment.<ref>Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P, Laporte S, Faivre R, Charbonnier B, Barral F, Huet Y, Simonneau G (1998). "A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group". N Engl J Med 338 (7): 409–15.</ref> Most newer filters can be removed after placement.<ref name=":1" /> Complications of this intervention include filter erosion, filter migration and obstruction of the inferior vena cava.<ref name=":1" />
* In conjunction with anti-coagulation, bed rest is commonly prescribed in the immediate days following the diagnosis of LE DVT. This practice is applied with the intent of preventing clot dislodgement and the incidence of PE. The theoretical basis behind this protocol has not been supported by the literature.<ref>Aissaoui N, Martins E, Mouly S, Wever S, Meune C. A meta-analysis of bed rest versus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both. Int J Cardiol 2009;137:37–41</ref><ref name=":7">Kahn SR, Shrier I, Kearon C. Physical activity in patients with deep venous thrombosis: a systematic review. Thromb Res 2008; 122:763–773</ref> According to a systematic review,<ref name=":7" /> early ambulation is associated with fewer incidences of new PE and decreased mortality. As such, early mobilization is instrumental for the prevention of DVT sequelae (see the next section on "Implications for Physical Therapy Practice" for guidelines on safe patient mobilization following known DVT).
 
Graduated Compression Stockings
=== Secondary Prevention ===
* To prevent DVT recurrence, the application of graduated compression stockings is recommended "beginning within 1 month of diagnosis of proximal DVT and continuing for a minimum of 1 year after diagnosis".<ref name="Snow">Snow V, Qaseem A, Barry P, et al. (2007). "Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians". Ann. Intern. Med. 146 (3): 204–10.</ref>
[[File:Compression stockings.jpg|thumb|271x271px]]
 
==== Early Mobilization ====
In conjunction with anti-coagulation, bed rest is commonly prescribed in the immediate days following the diagnosis of LE DVT. This practice is applied with the intent of preventing clot dislodgement and the incidence of PE. The theoretical basis behind this protocol has not been supported by the literature.<ref>Aissaoui N, Martins E, Mouly S, Wever S, Meune C. A meta-analysis of bed rest versus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both. Int J Cardiol 2009;137:37–41</ref><ref name=":7">Kahn SR, Shrier I, Kearon C. Physical activity in patients with deep venous thrombosis: a systematic review. Thromb Res 2008; 122:763–773</ref> Early ambulation is associated with fewer incidences of new PE and decreased mortality.<ref name=":7" /> and should be a priority once a patient is safe to do so (see the next secion on "Implications for Physical Therapy Practice" for guidelines on safe mobilization following known DVT).
 
==== Graduated Compression Stockings ====
The application of graduated compression stockings is recommended "beginning within 1 month of diagnosis of proximal DVT and continuing for a minimum of 1 year after diagnosis" to prevent DVT recurrence.<ref name="Snow">Snow V, Qaseem A, Barry P, et al. (2007). "Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians". Ann. Intern. Med. 146 (3): 204–10.</ref>  


== Implications for Physical Therapy Practice ==
== Implications for Physical Therapy Practice ==
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)<ref name=":8">Hillegass E, Puthoff M, Frese EM, Thigpen M, Sobush DC, Auten B. Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline. Phys Ther 2016; 96(2):143-66</ref> to facilitate clinical 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:
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)<ref name=":8">Hillegass E, Puthoff M, Frese EM, Thigpen M, Sobush DC, Auten B. Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline. Phys Ther 2016; 96(2):143-66</ref> <ref>Hillegass E, Puthoff M, Frese EM, Thigpen M, Sobush DC, Auten B, Guideline Development Group. Role of physical therapists in the management of individuals at risk for or diagnosed with venous thromboembolism: evidence-based clinical practice guideline. Physical therapy. 2016 Feb 1;96(2):143-66.</ref>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:
{| class="wikitable"
{| class="wikitable"
!PT Responsibilities
!PT Responsibilities
Line 159: Line 125:
* Recommend/use mechanical compression for individuals at moderate or high risk for DVT
* Recommend/use mechanical compression for individuals at moderate or high risk for DVT
* Consult with the physician about medication for individuals at moderate or high risk for DVT
* Consult with the physician about medication for individuals at moderate or high risk for DVT
* Provide education on DVT prevention (leg exercises, ambulation, hydration, mechanical compression, etc)
* Provide education on DVT prevention (leg exercises, ambulation, hydration, etc)
* Provide education on the risk factors, signs and symptoms and consequences of DVT
* Provide education on the risk factors, signs and symptoms, and consequences of DVT
|-
|-
|(2) Screening for LE DVT
|(2) Screening for LE DVT
|
|
* Screen for DVT risk using Well's Criteria or the preferred risk assessment model of the treating institution.
* Screen for DVT risk using Well's Criteria or the preferred risk assessment model of the treating institution.
* Communicate screening results and relevant clinical signs and symptoms to the medical team
* Communicate screening results and relevant clinical signs and symptoms to the medical team.
* Provide education on the importance of seeking medical attention for suspected DVT
* Provide education on the importance of seeking medical attention for suspected DVT.
|-
|-
|(3) Making prudent decisions regarding safe mobility in conjunction with the health care team
|(3) Making prudent decisions regarding safe mobility in conjunction with the health care team
|
|
* Advocate for diagnostic testing before mobilizing patients with suspected DVT
* Advocate for diagnostic testing and wait the results before mobilizing patients with suspected DVT
* Screen for fall-risk when a patient is on anticoagulation therapy
* Screen for fall-risk when a patient is on anticoagulation therapy
* Engage patients with known DVT in early mobilization. Recommendations for when and how it safe to mobilize a patient with known DVT depends on patient fall-risk the medical treatment being used:
* Engage patients with known DVT in early mobilization. Recommendations for how and when it is safe to mobilize a patient with known DVT depends on patient fall-risk the medical treatment being used:
{| class="wikitable"
{| class="wikitable"
!Medical Treatment
!Medical Treatment
Line 190: Line 156:
|Out of bed ordered for a patient with no anticoagulation therapy or IVC filter
|Out of bed ordered for a patient with no anticoagulation therapy or IVC filter
|
|
# Consult with the medical team regarding mobility vs, continued bed rest.
# Consult with the medical team regarding mobility vs continued bed rest.
|}
|}
|-
|-
Line 201: Line 167:
|(5) Patient education & shared decision making
|(5) Patient education & shared decision making
|
|
* Patient education should applied throughout the DVT prevention and management process.
* Patient education should be given throughout the DVT prevention and management process.
* Patients should have the autonomy to  
* Patients should have the autonomy to decide if they want to engage in recommended prevention and treatment measures. 
|}
|}
<nowiki>*</nowiki>NOTE: Execution of the above recommendations should be done in line with institution-specific policies. Hillegass et al<ref name=":8" /> offer a [https://academic.oup.com/view-large/figure/54632825/ptj0143-fig003.jpeg decision making algorithm] that may be helpful in the absence of or as a reference point for updating health care system protocols)
{{#ev:youtube|Ali7rFYfJuY}}
 
Resources
== Differential Diagnosis  ==
* [https://academic.oup.com/ptj/article/96/2/143/2686356 Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline.]<div class="coursebox"></div>
 
Below is a non-exhaustive list for the differential diagnosis of calf pain in patients with suspected LE DVT:<ref>Dutton. Orthopaedic Examination, Evaluation, and Intervention. McGraw Hill; 2004. pg 261, 1338, 1367.</ref><ref name=":6" />
 
*Pyomyositis
*[https://www.physio-pedia.com/Fibular_Fracture Fibula shaft fracture]
*[https://www.physio-pedia.com/Cellulitis Cellulitis]
*Ruptured [https://www.physio-pedia.com/Baker%27s_Cyst Baker's cyst]
*Neurogenic leg pain
*Hematoma
*[https://www.physio-pedia.com/Achilles_Rupture Rupture of Achilles Tendon]
*Soleus muscle strain
*Acute posterior [https://www.physio-pedia.com/Compartment_Syndrome_of_the_Lower_Leg compartment syndrome]
*Calf muscle cramps
 
== Resources   ==
* [https://academic.oup.com/ptj/article/96/2/143/2686356 Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline]
== Presentations  ==
<div class="coursebox">
{| width="100%" cellspacing="4" cellpadding="4" border="0" class="FCK__ShowTableBorders"
|-
| align="center" | <imagemap>
Image:Differential_Diagnosis_and_VTE.png|200px|border|left|
rect 0 0 830 452 [http://www.eimqa.com/Fellowship/FellowPresent/JogodkaVTE.mov]
desc none
</imagemap>
| [http://www.eimqa.com/Fellowship/FellowPresent/JogodkaVTE.mov '''Differential Diagnosis and VTE''']
This presentation, created by Carleen Jogodka as part of the [[Evidence In Motion]] OMPT Fellowship, discusses differential diagnosis for venous thromboembolism.
 
[http://www.eimqa.com/Fellowship/FellowPresent/JogodkaVTE.mov View the presentation]
 
|}
</div>
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<div class="researchbox">
<rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1lGTpA7S74wiuMUQ_tI6X1P9s02KQ2A3QIj_uTEdGv29exlk3C</rss>
</div>
 
== Read 4 Credit  ==
<div class="coursebox">
{| width="100%" cellspacing="1" cellpadding="1" border="0"
|-
| [[Image:Quiz-image.jpg|center|150px]]
|
Would you like to earn certification to prove your knowledge on this topic?
 
All you need to do is pass the quiz relating to this page in the Physiopedia member area.
 
[http://members.physio-pedia.com/quizzes/deep-vein-thrombosis/ Go to Quiz]
 
 
 
[http://members.physio-pedia.com/ Find out more about a Physiopedia membership]
 
|}
</div>


== References  ==
== References  ==
Line 267: Line 178:
<references />  
<references />  
<br>  
<br>  
[[Category:EBP]] [[Category:Elbow]] [[Category:Older_People/Geriatrics]] [[Category:EIM_Residency_Project]] [[Category:Musculoskeletal/Orthopaedics]] [[Category:Haemodynamics]]
[[Category:EBP]]  
[[Category:Older_People/Geriatrics]]
[[Category:EIM_Residency_Project]]  
[[Category:Musculoskeletal/Orthopaedics]]
[[Category:Primary Contact]]
[[Category:Acute Care]]
[[Category:Medical]]
[[Category:Cardiopulmonary]]
[[Category:Cardiovascular Disease - Conditions]]
 
[[Category:Acute Respiratory Disorders - Conditions]]
[[Category:Older People/Geriatrics - Conditions]]
[[Category:Non Communicable Diseases]]

Latest revision as of 15:05, 2 February 2023

Original Editor - Jennifer Self

Top Contributors - Admin, Karen Wilson, Kim Jackson, Laura Ritchie, Scott Buxton, Jennifer Self, Shaimaa Eldib, Lucinda hampton, Ayesha Arabi, WikiSysop, Adam Vallely Farrell and Claire Knott  

Introduction[edit | edit source]

DVT: R leg with swelling and redness

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]

  • 1.6 new cases per 1000 per year
  • 2.5-5% of the population is affected
  • >50% have long terms symptoms of post-thrombotic syndrome
  • 6% of DVT patients report eventual venous ulcers (0.1% general population)[3]

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]

Mapping the at-risk area for deep vein thrombosis

Following are the risk factors and are considered as causes of deep venous thrombosis:

  • Reduced blood flow: Immobility (bed rest, general anesthesia, operations or surgery[4], long flights)
  • Mechanical compression or functional impairment which reduces flow in the veins (eg neoplasm, pregnancy, varicose veins)
  • Mechanical injury to the vein eg Trauma, surgery, peripherally inserted venous catheters, previous DVT, intravenous drug abuse.
  • Increased blood viscosity eg thrombocytosis, dehydration
  • Anatomic variations in venous anatomy can contribute to thrombosis.

Increased Risk of Coagulation

Constitutional Factors

Clinical Presentation[edit | edit source]

Varicose veins of the great saphenous vein

History

  1. Pain (50% of patients)
  2. Redness
  3. Swelling (70% of patients)

Physical Examination

  1. Limb edema may be unilateral or bilateral if the thrombus is extending to pelvic veins
  2. Red and hot skin, with dilated veins
  3. Tenderness[2]

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]

Clinical Variable Score
Active cancer (treatment ongoing or within previous 6 months, or palliative) +1
Paralysis, paresis, or recent plaster immobilization of the lower extremities +1
Recently bed ridden for > 3 days or major surgery within 4 weeks[5] +1
Localized tenderness along the distribution of the deep venous system (Tenderness along the deep venous system is assessed by firm palpation in the center of the posterior calf, the popliteal space, and along the area of the femoral vein in the anterior thigh and groin) +1
Entire lower extremity swelling +1
Calf swelling > 3 cm when compared with the asymptomatic lower extremity (measured 10cm below the tibial tuberosity) +1
Pitting edema confined to the symptomatic lower extremity +1
Collateral superficial veins (non-varicose) +1
Alternative diagnosis as likely or greater than that of proximal DVT (More common alternative diagnoses include cellulitis, calf strain, Baker Cyst, or postoperative swelling) -2

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.[6] An updated version simplifies the scoring process into two categories: < 2 points= DVT unlikely, ≥ 2 points= DVT likely.[7]

Well's Criteria[8] is a valid tool for assessing DVT risk in outpatient[9][10] and trauma[11] patients. It is less useful for stratifying risk in cancer patients[10] and hospitalized patients as a whole.[12] It cannot be used to screen for UE DVT.[13]

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[14].

  • Focus on identifying the signs and symptoms described in the "Clinical Presentation" section of this article.

Homan's Sign

Diagnostic Procedures[edit | edit source]

Venography

As per the NICE guidelines following investigations are done:

  • D-dimers (very sensitive but not very specific)
  • Coagulation profile
  • Proximal leg vein ultrasound, which when positive, indicates that the patient should be treated as having a DVT[2]

D-Dimer Testing

  • D-dimer testing is a simple blood test of fibrin degradation. D-dimer levels are increased by any condition that produces fibrin, one of the primary components of deep vein thrombi. The negative likelihood ratio is higher than 99%. According to Wells and colleagues,[15] the test is best used to rule out DVT in outpatients with a low probability of proximal DVT.

Management / Interventions[edit | edit source]

Primary Prevention

A combination of mechanical and pharmacological measures can be used to prevent DVT[16]. 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).[17] 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

Compression stockings.

Early Mobilization

  • In conjunction with anti-coagulation, bed rest is commonly prescribed in the immediate days following the diagnosis of LE DVT. This practice is applied with the intent of preventing clot dislodgement and the incidence of PE. The theoretical basis behind this protocol has not been supported by the literature.[18][19] According to a systematic review,[19] early ambulation is associated with fewer incidences of new PE and decreased mortality. As such, early mobilization is instrumental for the prevention of DVT sequelae (see the next section on "Implications for Physical Therapy Practice" for guidelines on safe patient mobilization following known DVT).

Graduated Compression Stockings

  • To prevent DVT recurrence, the application of graduated compression stockings is recommended "beginning within 1 month of diagnosis of proximal DVT and continuing for a minimum of 1 year after diagnosis".[20]

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)[21] [22]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:

PT Responsibilities Actionable Recommendations
(1) Prevention of VTE
  • Encourage patient mobility and physical activity at the individual and institutional level.
  • Recommend/use mechanical compression for individuals at moderate or high risk for DVT
  • Consult with the physician about medication for individuals at moderate or high risk for DVT
  • Provide education on DVT prevention (leg exercises, ambulation, hydration, etc)
  • Provide education on the risk factors, signs and symptoms, and consequences of DVT
(2) Screening for LE DVT
  • Screen for DVT risk using Well's Criteria or the preferred risk assessment model of the treating institution.
  • Communicate screening results and relevant clinical signs and symptoms to the medical team.
  • Provide education on the importance of seeking medical attention for suspected DVT.
(3) Making prudent decisions regarding safe mobility in conjunction with the health care team
  • Advocate for diagnostic testing and wait the results before mobilizing patients with suspected DVT
  • Screen for fall-risk when a patient is on anticoagulation therapy
  • Engage patients with known DVT in early mobilization. Recommendations for how and when it is safe to mobilize a patient with known DVT depends on patient fall-risk the medical treatment being used:
Medical Treatment Safe Mobilization Guidelines
Anticoagulation
  1. Verify initiation of anticoagulation and type.
  2. Determine if therapeutic levels of anticoagulation have been achieved.
  3. Mobilize the patient once he/she is in a therapeutic range.*
IVC filter
  1. Verify placement of an IVC filter.
  2. Mobilize the patient once he/she is hemodynamically stable.*
Out of bed ordered for a patient with no anticoagulation therapy or IVC filter
  1. Consult with the medical team regarding mobility vs continued bed rest.
(4) Prevention of long-term consequences of LE DVT
  • Engage patients with known DVT in safe mobilization (review section 3 of this table for details).
  • Recommend/use mechanical compression.
  • Provide education on the risks and benefits of mobilization following DVT.
(5) Patient education & shared decision making
  • Patient education should be given throughout the DVT prevention and management process.
  • Patients should have the autonomy to decide if they want to engage in recommended prevention and treatment measures.

Resources

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 Kesieme E, Kesieme C, Jebbin N, Irekpita E, Dongo A. Deep vein thrombosis: a clinical review. J Blood Med 2011; 2:59–69.
  2. ↑ 2.0 2.1 2.2 2.3 Waheed SM, Kudaravalli P, Hotwagner DT. Deep vein thrombosis (DVT). StatPearls [Internet]. 2020 Aug 10. Available from:https://www.ncbi.nlm.nih.gov/books/NBK507708/ (last accessed 25.10.2020)
  3. ↑ 3.0 3.1 Radiopedia DVT Available:https://radiopaedia.org/articles/deep-vein-thrombosis (accessed 19.7.2022)
  4. ↑ Solis G, Saxby T. Incidence of DVT following surgery of the foot and ankle. Foot & ankle international. 2002 May;23(5):411-4.
  5. ↑ Song K, Yao Y, Rong Z, Shen Y, Zheng M, Jiang Q. The preoperative incidence of deep vein thrombosis (DVT) and its correlation with postoperative DVT in patients undergoing elective surgery for femoral neck fractures. Archives of orthopaedic and trauma surgery. 2016 Oct;136:1459-64.
  6. ↑ Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C, Weitz J, D'Ovidio R, Cogo A, Prandoni P.  Accuracy of clinical assessment of deep-vein thrombosis. Lancet 1995; 345(8961):1326-1330
  7. ↑ Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C, Dreyer J, Kovacs G, Mitchell M, Lewandowski B, Kovacs MJ. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med 2003; 349:1227–1235
  8. ↑ Modi S, Deisler R, Gozel K, Reicks P, Irwin E, Brunsvold M, Banton K, Beilman GJ. Wells criteria for DVT is a reliable clinical tool to assess the risk of deep venous thrombosis in trauma patients. World Journal of Emergency Surgery. 2016 Dec;11:1-6.
  9. ↑ Wells  PS, Anderson  DR, Bormanis  J, Guy F, Mitchell M, Gray L, Clement C, Robinson KS, Lewandowski B. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet 1997; 350(9094):1795-1798
  10. ↑ 10.0 10.1 Geersing  GJ, Zuithoff  NPA, Kearon  C, Anderson DR, Cate-Hoek T, Elf JL, Bates SM, Hoes AW, Kraaijenhagen RA, Oudega R, Schutgens RE, Stevens SM, Woller SC, Wells PS, Moons KG. Exclusion of deep vein thrombosis using the Wells rule in clinically important subgroups: individual patient data meta-analysis. BMJ 2014; 348:g1340
  11. ↑ Modi S, Deisler R, Gozel K, Reicks P, Irwin E, Brunsvold M, Banton K, Beilman GJ. Wells criteria for DVT is a reliable clinical tool to assess the risk of deep venous thrombosis in trauma patients. World J Emerg Surg. 2016; 11: 24
  12. ↑ Silveira PC, Ip IK, Goldhaber SZ, Piazza G, Benson CB, Khorasani R. Performance of Wells Score for Deep Vein Thrombosis in the Inpatient Setting. JAMA Intern Med 2015; 175(7):1112-7
  13. ↑ Heil J, Miesbach W, Vogl T, Bechstein WO, Reinisch A. Deep vein thrombosis of the upper extremity: A systematic review. Dtsch Arztebl Int 2017; 114(14): 244–249
  14. ↑ Scarvelis D, Wells PS. Diagnosis and treatment of deep-vein thrombosis. Cmaj. 2006 Oct 24;175(9):1087-92.
  15. ↑ Riddle DL, Wells PS. Diagnosis of Lower-Extremity Deep Vein Thrombosis in Outpatients. Physical Therapy. 84 (8); 729-735.
  16. ↑ Morillo R, Jiménez D, Aibar MÁ, Mastroiacovo D, Wells PS, Sampériz Á, De Sousa MS, Muriel A, Yusen RD, Monreal M, Decousus H. DVT management and outcome trends, 2001 to 2014. Chest. 2016 Aug 1;150(2):374-83.
  17. ↑ Joffe H, Kucher N, Tapson V, Goldhaber S. Upper-extremity deep vein thrombosis: a prospective registry of 593 patients. Circulation 2004; 110: 1605-1611
  18. ↑ Aissaoui N, Martins E, Mouly S, Wever S, Meune C. A meta-analysis of bed rest versus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both. Int J Cardiol 2009;137:37–41
  19. ↑ 19.0 19.1 Kahn SR, Shrier I, Kearon C. Physical activity in patients with deep venous thrombosis: a systematic review. Thromb Res 2008; 122:763–773
  20. ↑ Snow V, Qaseem A, Barry P, et al. (2007). "Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians". Ann. Intern. Med. 146 (3): 204–10.
  21. ↑ Hillegass E, Puthoff M, Frese EM, Thigpen M, Sobush DC, Auten B. Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline. Phys Ther 2016; 96(2):143-66
  22. ↑ Hillegass E, Puthoff M, Frese EM, Thigpen M, Sobush DC, Auten B, Guideline Development Group. Role of physical therapists in the management of individuals at risk for or diagnosed with venous thromboembolism: evidence-based clinical practice guideline. Physical therapy. 2016 Feb 1;96(2):143-66.


Retrieved from "https://www.physio-pedia.com/index.php?title=Deep_Vein_Thrombosis&oldid=326505"