Risk Modeling, Assessment, and Management, 3rd edition, Supplementary Problems and Exercises

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This narrowing of the lumen may lead to reduced oxygenation and pulmonary hypertension. Chronically, the infarction of lung tissue following PE may result in a reduction of vascularization and concomitant pulmonary hypertension. Over time, the workload imposed on the right heart increases and contributes to right heart dysfunction and then failure. Additionally, damage to the vein itself occurs and leads to inflammation and necrosis of the vein, which eventually are removed by phagocytic cells, leading to venous hypertension.

This impaired blood flow can lead to classic symptoms of PTS, which often includes chronic aching pain, intractable edema, limb heaviness, and leg ulcers. The physical therapist's responsibility to every patient is 5-fold: 1 prevention of VTE, 2 screening for LE DVT, 3 contributing to the health care team in making prudent decisions regarding safe mobility for these patients, 4 patient education and shared decision making, and 5 prevention of long-term consequences of LE DVT. Such decisions should always be made in collaboration with the referring physician and other members of the health care team ie, it is assumed that such decisions will not be made in isolation and that the physical therapist will communicate with the medical team.

Due to the long-standing controversy regarding mobilization versus bed rest following VTE diagnosis and with the development of new anticoagulation medications, the physical therapy community needs evidence-based guidelines to assist in clinical decision making. This CPG is intended to be used as a reference document to guide physical therapist practice in the prevention of, screening for, and treatment of patients at risk for or diagnosed with LE DVT.

This CPG is based on a systematic review of published studies on the risks of early ambulation in patients with diagnosed DVT and on other established clinical guidelines on prevention, risk factors, and screening for VTE and PTS. In addition to providing practice recommendations, this guideline also addresses gaps in the evidence and areas that warrant further investigation. Specifically, the role of mobility was identified as a major issue facing both sections.

In addition, topic areas were solicited from clinicians with content experience in the area of VTE who volunteered to assist. A resultant list of topic areas was developed to determine the scope of the CPG and provided the GPG with limits to the literature search. A search strategy was developed and performed by a librarian to identify literature published between May 1, , and May addressing mobilization and anticoagulation therapy to prevent and treat VTE. Results were limited to articles written in English.

The search strategy by key words, MeSH terms, and databases is shown in Table 2. The NGC database identified guidelines, of which 40 were deemed as appropriate to be reviewed. Three additional guidelines were identified through the Trip database, and the appropriate target populations were included. The results of the literature and guideline searches were distributed to the members of the GDG.

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One member of the group reviewed a list of citations, and another member performed a second review of the same list of citations. Articles were included based on whether key topics were addressed and the appropriate target populations were included. Case reports and pediatric articles were excluded.

Reliability of appraisers was established prior to articles being reviewed. Selected articles were reviewed by 3 individuals who used 1 of 3 critical appraisal tools adapted from an evidence-based practice textbook to evaluate each according to its type ie, critical appraisal for studies of prognosis, diagnosis, or intervention. Interrater reliability among the 4 core group members was first established on test articles. Volunteers completed critical appraisals of the test articles to establish interrater reliability. Appraisers were randomly paired to read each of the remaining diagnostic, prognostic, or intervention articles.

Discrepancies in scoring between the readers were resolved by a member of the GDG. Clinical practice guidelines were reviewed that fit the scope of this CPG and the patient population. Guidelines were included based on whether key topics were addressed and the target populations were included. Table 4 presents the criteria for the grades assigned to each action statement.

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The grade reflects the overall and highest levels of evidence available to support the action statement. Levels of Evidence a.

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Developing evidence-based physical therapy clinical practice guidelines. Pediatr Phys Ther.

Lecture 22: Risk Assessment

Grades of Recommendation for Action Statements a. Statements that received an A or B grade should be considered as well supported. The CPG lists each key action statement followed by rating of level of evidence and grade of the recommendation. Under each statement is a summary providing the supporting evidence and clinical interpretation. The statements are organized in Table 1 according to the action statement number, the statement, and the key phrase or action statement. This CPG underwent 2 formal reviews. First, draft reviewers were invited stakeholders representing the American College of Chest Physicians, Society for Vascular Nursing, physical therapy clinicians and researchers, and patient representatives.

The action statement profile describes the benefits, harms, and costs associated with the recommendation; a delineation of the assumptions or judgments made by the GDG in formatting the recommendation; reasons for any intentional vagueness in the recommendation; and a summary and clinical interpretation of the evidence supporting the recommendation. The Delphi process was used to determine level of evidence and recommended strength for each key action statement.

Each member of the GPG reviewed the supporting evidence for each key action statement and voted on level of evidence and strength of recommendation independent of the other group members using a Google survey upon which all votes were tallied and then reported. This CPG uses literature available from through to address the following aspects of physical therapists' management of patients with potential or diagnosed VTE.

Clinical practice algorithms Figs. Algorithm for mobilizing patients with known lower extremity deep vein thrombosis.


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Use LMWH guidelines for mobilization decision in these situations. Physical therapists and other health care practitioners should advocate for a culture of mobility and physical activity. Value Judgments: Physical therapists should advocate for mobility in all situations due to the evidence on the benefits of activity and risks associated with inactivity and bed rest except when there could be a risk of harm eg, emboli depositing in the pulmonary system. Role of Patient Preferences: As the evidence for risks associated with inactivity is strong and with little associated risk of mobility in the absence of thromboembolism, patients should be educated regarding the benefits of mobility and encouraged to maintain mobility as much as possible to decrease the risk of adverse outcomes.


Reduced mobility is a known risk factor for VTE, yet the quantity and duration of the reduced mobility that defines degree of risk for VTE are not known. When additional risk factors for VTE are present in an individual who has any reduction in mobility, the risk for VTE is significantly increased. Increased age serves as an example.

One study of hospitalized patients older than 65 years found reduced mobility to be an independent risk factor for VTE. The risk increased based on the degree of immobility, and relative risk scores were derived according to the degree of immobility Tab. Recent national guidelines have associated reduced mobility with increased risk for VTE.

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When patients undergo surgery with an anesthesia time of greater than 90 minutes or if the surgical procedure involves the pelvis or lower limb and anesthesia time is greater than 60 minutes, the risk is much greater. Individuals who are admitted acutely for surgical reasons or admitted with inflammatory or intra-abdominal conditions also are at high risk for developing a VTE.

These same guidelines emphasized the need to identify all individuals who are expected to have any significant reductions in mobility to be at risk for VTE and to mobilize them as soon as possible. Previously, when individuals were diagnosed with an LE DVT, they were placed on bed rest due to the concern that ambulation would cause clot dislodgment and lead to a potentially fatal PE.

However, a meta-analysis compiled data from 5 randomized controlled trials RCTs on more than 3, patients and concluded that early ambulation following diagnosis of an LE DVT was not associated with a higher incidence of a new PE or progression of LE DVT compared with bed rest.

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  • Similar findings, as well as more rapid resolution of pain, were reported in a systematic review that included 7 RCTs and 2 prospective observational studies. In summary, mobility should be encouraged in patients while in the hospital and when discharged to prevent the complications associated with immobility. In addition, mobility is recommended for those diagnosed with VTE once therapeutic anticoagulant levels have been reached see Action Statement 8. Intentional Vagueness: Physical therapists should work within their health care system to determine specific algorithms or risk assessment models RAMs to use.

    The Guide to Physical Therapist Practice states that the physical therapist examination is a comprehensive screening and specific testing process leading to diagnostic classification or, as appropriate, to a referral to another practitioner. During the patient interview, physical therapists should ask questions and review the medical history to determine whether the patient is at risk for LE DVT. Risk factors include previous venous thrombosis or embolism, age, active cancer or cancer treatment, severe infection, oral contraceptives, hormonal replacement therapy, pregnancy or given birth within the previous 6 weeks, immobility bed rest, flight travel, fractures , surgery, anesthesia, critical care admission, central venous catheters, inherited thrombophilia, and obesity.

    The relationship between particular risk factors and presence of LE DVT has been found through retrospective and prospective studies and identified as having support from level I evidence in other CPGs. The need for all health care providers to screen for risk of LE DVT through system-wide approaches has been highlighted by the US Agency for Healthcare Research and Quality, 35 the Finnish Medical Society, 31 and the Scottish Intercollegiate Guidelines Network, 36 and such screening is strongly recommended by each of these groups. Furthermore, the importance of screening was strongly supported in a multinational cross-sectional study of patients from more than hospitals across 32 countries.

    The findings revealed that To facilitate and standardize the process of screening for risk within health care systems and across professions, RAMs should be considered. If a set point level is reached, the patient is considered at an increased risk, and more aggressive prophylactic interventions can be used. It is more important that physical therapists work within their health care system to understand and even help develop an overall VTE protocol that uses an agreed-upon tool for VTE risk assessment.

    In summary, given the risks and harms associated with a VTE and the relationship of VTE incidence to the presence of risk factors, physical therapists should screen for VTE risk. These results should be communicated with the rest of the health care team. These measures should include education regarding signs and symptoms of LE DVT, activity, hydration, mechanical compression, and referral for medication assessment.

    Role of Patient Preferences: Patients may or may not choose to adhere to preventive measures. There is a role for having shared decision making with regard to their priorities. For individuals who are at risk for LE DVT, preventive measures should be initiated immediately, including education regarding leg exercises, ambulation, proper hydration, mechanical compression, and assessment regarding the need for medication referral.

    Documentation of the patient's understanding of these concepts also should be included.