DVT Management for Physiotherapists: Signs, Well Score & Mobilization Guidelines

so as a physiotherapist it's really important that we have an understanding of the medical management for dvts so in

this video i'm going to be highlighting to you what a dvt is and the key things that we need to do to help manage these

patients in practice so if that sounds good let's dive in hey guys i'm khalid welcome back to

clinical physio so dvt stands for deep vein thrombosis which quite simply is described as a blood clot within the

veins a blood clot or thrombus is a mixture of blood components including red blood cells platelets and fibrin

which clump together in a complex series of events known as the clotting cascade in a deep vein thrombosis the veins

affected are not those veins you can see on the surface of your skin but much deeper within our limbs in our body

the most commonly affected veins are within the legs and tend to be that of the femoral vein

the popliteal vein the posterior tibial vein and the perineal veins

actually 90 of all dvts are in the lower limb and around 10 in the upper limb this is because blood

more easily pools within the veins of the lower limb and when blood remains stationary it is more likely to activate

the clotting pathways to form a clot so as we've said more stationary blood increases the risk of clotting and

therefore dvts but there are other components that will also do the same and these can be remembered with

virchow's triad virtua's triad was created by a german physician rudolf verchow and he

identified three key components in the development of a blood clot so the first component is stasis when we have

stationary pooling of blood we've mentioned this already it commonly occurs during long car journeys long

plane journeys especially when people are dehydrated but also can be a factor when patients are bed bound for long

periods of time in hospital all of this reduces blood flow particularly in the legs and thus can be an increased risk

for clotting the second component is endothelial injury so our endothelium is the lining of our blood vessels and

therefore endothelial injury means blood vessel wall injury so this can happen when there's a trauma such as a fracture

perhaps when a needle is inserted perhaps during a medical procedure and infections can also lead to endothelial

injury in the veins and if you're thinking about arteries we might think about something like atherosclerosis

where we have the fatty buildup of plaque in those arteries which can mean endothelial injury and the third

component is hypercoagulability which simply means a person has an increased risk generally

of developing a clot this could be because of inherited factors or required factors inherited factors might be

disorders such as factor v leiden or a protein c deficiency and acquire disorders might occur when

someone has had an operation someone who's a smoker someone who has cancer someone who is pregnant or the oral

contraceptive pill are all examples of where we can have acquired hypercoagulability

so that's the theory now on to the signs and symptoms and there are three classical signs that we see time and

time again with our dvts swelling pain and redness or heat

so swelling quite simply an increase in the size of the area where the clot has developed compared to the other side

quite classically in the calf you'll see this and you can measure the difference between the two to look at swelling and

in particular you might see the presence of pitting edema so this is when the limb is so swollen that when you press

your finger into it it creates an indentation that doesn't bounce back as you might expect normally when you put

your finger in swelling and that is called pitting edema so the second is pain and we're looking

at pain specifically in the area where this clot has formed this is often described as a very deep very

unremitting very excruciating pain once again we see this when patients have dvts in the calf

and the third factor is we said redness and heat so you might notice that the limb appears red and almost shiny and it

might naturally be hot to touch now this is often different to the redness that you see when your patient might have

cellulitis and therefore doctors when they're diagnosing a dvt will often be thinking about this differential

diagnosis for these patients so it's really important to know those key three signs but it's important to say that we

can't rely on those signs only to diagnose a dvt because they're not that sensitive and so instead the well score

was developed based on studies from 1995 to 2003 which looked at common characteristics for patients with a dvt

and you can see the well score here on the screen now so the idea being is that we would take

our patient through the well score and it will come up with a number at the end if that number is one or less it

identifies that there's a lower probability that our patient has a dvt and we can move on and consider other

diagnoses however if our patient has a score of two or more then it actually increases

the likelihood and risk that our patient has a dvt and they should go on to have further investigations so if the well

score is increased the first investigation your patient may have is a d-dimer test

this is a particular blood test where the d-dimer marker indicates inflammation now this can be raised in

lots and lots of different medical conditions so effectively when we do the d-dimer we're looking for a normal

result i.e that the d-dimer is not raised because this is pretty accurate at excluding a dvt

however if the d-dimer is raised our patient may then go on to have an ultrasound scan specifically of the area

in which the dvt is suspected so that we can use imagery to rule in or rule out the dvt so on to treatment if your

patient is diagnosed with a dvt they will be prescribed anticoagulant medication or blood thinning medication

examples of these include an oxaparin which is injection based warfarin one you'll see all the time in your patients

drug histories and more recently the use of a particular type of drug called a doac direct acting oral anticoagulants

and examples of these might include rivaroxaban or epix so your patient will be using these

medications for around about six months before they have a review with a hematologist now the hematologist may

suggest at that point that they can stop the medication but if there is perceived to be an increased risk that your

patient might develop more blood clots in the future they might be told that they have to continue taking that

anticoagulant medication forever so a couple of important and often overlooked facts about dvts the first is that

anticoagulant medication doesn't actually break down the clot which is popular belief

instead anticoagulants aim to prevent further clots from developing and the idea is that our body aims to naturally

break down the existing clots over the weeks and months ahead the second important point is the reason we worry

about dvts which is not really because of the dvt itself it is because if left untreated they are

likely to form a long column of blood clots normally in the leg and that creates the risk of a piece of

that thrombus breaking off when it is then known as an embolus and traveling to the lungs where it can

lodge into the lung blood vessels creating a pe a pulmonary embolism which are much more dangerous

in patients with the dvt up to 50 percent can have a pe and also if you look at patients with a

pe around a third of them will also have a dvt at that time as well and that is why it's really important to treat them

so on to the third really important point which is relevant to our physiotherapy management so it was

previously believed that if your patient on the ward was diagnosed with a dvt they should be confined to bed rest and

that's because it was believed that if they were mobilized it would encourage a piece of that clot to break off and

travel to the lungs to cause a pe or perhaps worse travel to the brain and cause a stroke

however that is now not the best management for these patients as highlighted by liu etal

2015 they found that compared to conventional bed rest early ambulation was not associated with progression of a

dvt or the development of a pe secondly they found that early

ambulation also appears to help reduce the acute symptoms and in particular our patients pain levels so whilst we can't

give a blanket statement because every patient is different and their symptoms and situation is different what this

does tell us is that if your patient has a dvt alone early ambulation doesn't have to be avoided what we would suggest

is that if your patient has a dvt make sure you check with your patients medical team if it's okay for them to

mobilize and if you are in a ward environment make sure it's documented in the notes so that you can make sure that

you're safe for yourself as well as for your patient so guys that's the end of this video i

really hope you've enjoyed it and if you have please smash that like button we'd really appreciate your support and you

can see more of us at our website clinicalphysio.com my name is khalid maydan thank you so

much for watching and we'll see you really soon right here on clinical physio