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Table 1: Diagnosis of Subjects handling of the lower extremity were allowed until return to
Diagnosis Non-PE 1%) PE 1%) physical therapy was ordered.
Seventy-seven non-PE patients and two PE patients were
Stroke 38 (29.9%) 1 (0.8%)
Hip fracture 16 (12.6%) 0 (0%) treated with the standard regimen of intravenous heparin for 3
SCI 13 (10.2%) 1 (0.8%) to 5 days until therapeutic PTT levels were reached (mean time
THA 8 (6.3%) 0 (0%) of 35.9 hours for the non-PE patients and 21 hours for the PE
TKA 6 (4.7%) 1 (0.8%) patients @ = .47)). Coumadin was usually started on the same
Deconditioning 6 (4.7%) 1 (0.8%)
ICH 4 (3.1%) 1 (0.8%) day if heparin was used. Thirty-three patients in the non-PE
SAH 4 (3.1%) 0 (0%) group and three patients in the PE group were treated with an
SDH 3 (2.4%) 1 (0.8%) IVC filter because of increased risk of bleeding. The rest of the
GBS 3 (2.4%) 0 (0%) patients were treated with subcutaneous heparin because of the
Cancer 3 (2.4%) 0 (0%)
Miscellaneous 11 (8.7%) 0 (0%) perceived decreased risk of embohzation of a below-knee DVT.
In one of these below-knee DVT patients, a PE developed.
Abbreviations: SCI, spinal cord injury; THA, total hip arthroplasty; TKA,
The data were analyzed statistically with a student t test to
total knee arthroplasty; ICH, intracerebral hemorrhage; SAH, subarach-
noid hemorrhage; SDH, subdural hematoma; GBS, Guillain-Barre syn- compare the difference in time (in hours) until return to physical
drome. therapy between those patients who developed a PE and those
who did not have a PE. The data were then reanalyzed regarding
two possible sources of bias: (I) Patients who were transferred
collected were age, sex, admission diagnosis, DVT prophylaxis, for treatment of their DVT, only to return in several days for
diagnostic method for DVT or PE, treatment for DVT, and time continued rehabilitation, were discarded. It had to be assumed
to mobilization after diagnosis of a DVT. One hundred twenty- that they were on continued bed rest until return, but this might
seven patients (73 females, 54 males), ages 16 to 95yrs (X = not have been the case (10 cases, all without a PE). (2) One
658yrs). with diagnosis of DVT were included in the study. A DVT case (without subsequent PE) was eliminated because the
DVT was diagnosed by either Doppler ultrasound (12 I patients) patient had a concomitant cellulitis which required a prolonged
or venogram (6 patients). A PE was diagnosed if there were time on bed rest.
clinical symptoms of a PE and a high probability V/Q scan, or The data were then stratified by time to return to physical
a V/Q scan suggestive of a PE with a high clinical suspicion therapy, and Fischer exact tests were done comparing patients
for a PE. Doppler ultrasound testing was conducted at two who were mobilized before versus after 48 hours. and before
different labs (Acuson 128XP/lo and ATL Ultramark 9 HDI). versus after 72 hours.
Both used color-flow Doppler and calf compression augmen-
tation. The V/Q scans were done at one location, using posterior RESULTS
oblique ventilation views and multiple perfusion views, on sev- The mean time until return to physical therapy in the 121
eral different scanners (Siemens ZLC, Elscint Varicam,d and patients without a PE was 123.2 hours. In the 6 patients diag-
SMV T-22). nosed with a PE it was 48.3 hours. This was a significant differ-
Patients were excluded for the following reasons: ence with a p value of .021 (I = 2.34 with 125 d. When the
They were transferred to an acute care hospital for treat- ten patients who were transferred to an acute setting for the
ment of their DVT and did not return to rehabilitation. treatment of their DVT and eventually returned to the rehabilita-
These patients were lost to follow-up, and it was suspected tion setting (none of whom developed a PE) were removed
that they remained in bed for medical treatment (23 cases). from the analysis, the mean time for the remaining 111 patients
They had a PE diagnosed at the same time or before they without a PE decreased to 114.1 hours but remained signifi-
were diagnosed with their DVT (36 cases). cantly different with a p value of .028 (t = 2.23 with 115 df).
The DVT was diagnosed before admission to the rehabili- When the patient with the concomitant lower extremity cellulitis
tation setting and the patient was already anticoagulated was also eliminated from the analysis, the mean time to return
or had an inferior vena cava (IVC) filter (5 cases). to physical therapy decreased to 111.4 hours but significance
One hundred twenty-one cases (ages 16 to 95yrs, x = 65.7yrs) was maintained at a p value of ,023 (t = 2.3 1 with 114 df,
had a DVT without a subsequent PE. Six cases with PE subse- (table 2).
quent to a DVT (ages 35 to 8lyrs, x = 66.5yrs) were found. Using the stratified data, categorical analysis with the Fischer
None of these patients had a poor outcome. The patients in this exact test was done by comparing the patients in two separate
study had multiple primary diagnoses that put them at risk of 2 X 2 analysis tables: one for patients who returned to physical
a DVT (table I). Twenty-seven patients in the non-PE group therapy before and after 48 hours, and the other for those who
were on DVT prophylaxis before being diagnosed with a DVT returned to physical therapy before and after 72 hours. The
(IO on Coumadin, 8 with lower extremity compression hose, Fischer exact test comparing the patients who were returned to
3 on heparin subcutaneously, 2 with an IVC filter already therapy at 48 hours or less compared to longer than 48 hours
placed, and 2 with sequential compression hoses), compared to revealed a statistically significant difference 0, = .018). The
none in the PE group. There were 4 cases of cardiac arrest
believed to be secondary to a PE, two proven by autopsy, but
Table 2: Mean Time Until Return to Physical Therapy
none of these patients had a DVT diagnosed before the untoward After DVT Diagnosis
event and were excluded from the study.
Non-PE PE p value
Time to mobilization was difficult to determine from the
chart, but time to return to physical therapy was well docu- Mean time until physical 123.2 hours 48.3 hours ,021
mented and was used as the point of aggressive mobilization therapy (/I = 121) (n = 6)
Mean time until physical 114.1 hours 48.3 hours ,028
of the affected limb. This time was determined based on the therapy excluding In = 111) (n = 6)
time the order was taken off of the physicians order sheet by acute transfers
the unit clerk. The return to physical therapy was confirmed Mean time until physical 111.4 hours 48.3 hours ,023
therapy excluding (n = 110) In = 6)
using physical therapy billing records. Most charts reviewed had cellulitis case
orders specifying bathroom privileges, but no ROM activities or
Table 3: Subjects Stratified by Time to Remobilization A floating thrombus as seen by Caprini et al3 and Berry
Time to Number Number et al4 was not noted on any of the Doppler ultrasound exams
Remobilize Without PE 1%) With PE 1%) reviewed in this study. It was either not looked for in the ultra-
~48 hours 22 (17.3%) 4 (3.1%) sound studies, was missed, or did not occur in this study sample.
48-72 hours 15 (11.8%) 0 (0%) Despite these problems, this study provides some valuable
>72 hours 84 (86.1%) 2 (1.6%) information. All six patients with PE did well and eventually
completed their rehabilitation course. The patients who died
from cardiac arrest were not diagnosed with a DVT before the
significant difference was lost when comparing the group held fatal attack. None of the patients who developed a PE received
out of therapy for 72 hours or less to the group that returned thromboprophylaxis, because they were believed to be at low
to physical therapy in more than 72 hours @ = .059) (table 3). risk of a DVT, or it was contraindicated as in the subdural
None of the venograms or Duplex ultrasound exams mentioned hematoma and intracerebral hemorrhage cases. This points to
a floating thrombus. the need to aggressively provide prophylaxis for patients at
risk for a DVT, especially in the rehabilitation setting. In a
DISCUSSION retrospective autopsy study of patients whose primary cause of
The diagnosis of a DVT is a particular problem for the reha- death was PE, Morgenthaler and Ryu* noted that only 22% of
bilitation specialist who is attempting to improve patients mo- patients were tested for DVT; in only 49% was the diagnosis
bility and independence. The most conservative accepted of PE considered; and in only 32% was PE correctly listed as
treatment has been bed rest with immobility of the affected limb the cause of death. As Mose? succinctly stated in an editorial,
for 10 to 14 days. However, this puts the patient at risk for Massive, fatal PE can be the first symptom of extensive DVT.
further deconditioning and other perils of immobility. Also, the Only prophylaxis can avoid such an event.
economics of medicine encourage earlier and earlier discharges.
The results of this study suggest that there is an increased risk CONCLUSION
of PE in patients who are aggressively mobilized less than 48
to 72 hours after diagnosis of a DVT. It is imperative that patients at risk of DVT receive thrombo-
There are several factors in this study that make interpretation prophylaxis, if it is not contraindicated. The possibility of in-
difficult: creasing the patients risk of a PE with early mobilization de-
1. Many cases and controls were excluded because they were serves a large cohort prospective study to fully answer the
transferred out of the rehabilitation setting; their eventual question. Until that is done, clinicians must use their best clini-
outcome is unknown. It is likely that they were treated cal judgment to determine when to return a patient with an
with anticoagulation and bed rest, and did not receive acute DVT to ambulation and physical therapy. At least 48 to 72
physical therapy in the acute care hospital. hours of bed rest would be prudent before return to mobilization.
2. We were unable to determine the degree of immobility
and restrictions to mobility except for time to return to References
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