Deep venous thrombosis is a common clinical problem, especially in patients with long-term braking. DVT not only causes pain to patients, but also seriously affects their functional recovery and rehabilitation treatment, and even endangers their lives. This article briefly introduces the influence of braking on DVT formation, rehabilitation prevention and rehabilitation treatment of DVT.
I. The effect of braking on the formation of DVT
Braking means that the body is forced to be at rest for a long time, and the common causes include bed rest, local immobilization and neurological paralysis. Braking is the most common medical measure, and for patients with serious diseases and injuries, braking is beneficial to protect damaged tissues, reduce tissue burden, maintain the stability of the condition and natural recovery process.
DVT is one of the common complications of braking.
1, blood volume decreased from the upright position to the lying position, the lower extremities have 500-700ml blood volume immediately into the central circulation, the right atrial pressure rapidly increased, atrial pressure receptors excitation, to the cardiovascular center issued the “blood volume too much” signal. The cardiovascular center regulates this by decreasing the secretion of antidiuretic techniques, so that renal tubular reabsorption decreases and urine increases. The fact that we have to urinate every morning and feel thirsty is the result of blood volume regulation.
2. The blood flow velocity decreases by 24.4% in the abdominal aorta and 50% in the femoral artery after bed rest, and also decreases in the middle cerebral artery, but the coronary artery flow velocity remains unchanged. The venous flow resistance of the lower extremities increased by 91%, the venous compliance increased, and the blood flow velocity slowed down significantly.
3.Blood viscosity increases due to the decrease of blood volume, but not the decrease of organic fraction in blood, resulting in a significant increase of blood viscosity.
4.The chance of thrombosis increases due to the increase of blood viscosity and slow blood flow, which increases the chance of thrombosis significantly, the most common ones are deep vein thrombosis, thrombotic vasculitis and pulmonary embolism. This is the basic principle of the possibility of DVT formation in long-term bedridden patients up to 15%-50%. the occurrence of DVT is mostly in the lower limbs, leading to severe edema in the lower limbs, often combined with infection; deep vein embolism dislodged can cause lethal pulmonary embolism, and the morbidity and mortality rate is high.
II. Prevention of DVT
The international neglect of venous thrombosis prevention is widespread. In a study of 5451 DVT patients in 183 hospitals in the United States, it was found that 3894 (71%) had no preventive measures, of which 2295 (59%) were non-surgical patients. the key measure of DVT prevention is to remove the basic factors that induce thrombosis, which include.
1, appropriate body position often take upright position is the most common and effective measures. For patients who can sit and stand on their own, patients should be encouraged to have a sitting and standing position several times a day. If patients cannot sit and stand independently because of their condition, such as patients with spinal fractures and spinal cord injuries, they can also take the way of rocking the head of the bed high and sitting against the bed.
2.Adequate water and fluid intake is necessary to prevent DVT because the patient’s blood volume is reduced. When replenishing body fluid, not only urine volume but also non-significant water loss should be considered, which is caused by water vapor excretion from exhalation and skin sweating. Non-significant water loss is approximately 800 ml/day. In the case of strenuous exercise, heat and sweating, water loss is more serious.
3.Appropriate physical activity Appropriate physical activity can promote venous blood flow and prevent the occurrence of DVT through the action of muscle pump. In the case that the patient’s injury site is unstable, activities can be performed in the non-injury site. For example, patients with spinal fractures can do lower and upper extremity activities; patients with lower extremity paralysis can be encouraged to perform upper extremity activities; patients with femur fractures can perform ankle joint activities.
Even at the fracture site, performing muscle isometric contraction, i.e., exercises that have muscle contraction but do not cause joint activity, is an effective way to prevent DVT and also helps to promote fracture healing. Patients with cardiopulmonary disease should be careful when performing physical activities that the intensity of the exercise is not too high.
In general, light non-resistance physical activity has minimal physical load and rarely induces cardiovascular and respiratory problems. ECG and oxygen saturation monitoring can be used during exercise or activity, respectively, if necessary. In cases where active activity is not possible, gentle passive exercise is also valuable.
4.Early activity on the ground early into walking is beneficial to prevent the occurrence of DVT. Clinical experience shows that DVT rarely occurs in patients who have resumed walking.
5.Use of drugs that reduce blood viscosity Aspirin is the most common drug. Other anticoagulants are also drugs that can be considered, especially for patients with a history of thrombosis.
6.Pay attention to the early manifestation of DVT Pay attention to the early manifestation of DVT formation and take active measures, which can effectively prevent and stop the progress of the lesion. The main points of observation include: the skin temperature, color and elasticity of the limb; the circumference and pressure pain of the limb; and the abnormal sensation of the patient.
Early swelling in DVT often manifests as diffuse limb swelling with high tension, skin temperature may increase, there is pressure pain, and the swelling develops gradually from the distal to the proximal end of the limb. In later stages, it manifests as sunken edema. If there is obvious local swelling of the limb, but not the distal limb, the most common possibility is heterotopic ossification, not DVT.
III. Rehabilitation treatment of DVT
For patients who have developed DVT, the goal of rehabilitation treatment is to reduce symptoms, promote revascularization, and eliminate various risk factors that induce thrombosis. Commonly used measures include.
1. Postural treatment often uses upright posture, such as sitting. The duration of uprightness should not be too long, usually within 30 minutes. Lower limb elevated position is adopted when lying down. The affected limb is usually elevated 20-30 cm above the heart level to promote venous return and reduce limb swelling. Usually pillow elevation is taken in the supine position.
2. Compression therapy usually uses special compression stockings or compression cuffs. The production of compression stockings and compression cuffs requires a pressure gradient from distal to proximal, i.e., maximum pressure at the distal end and minimum pressure at the proximal end. Elastic bandages can also be used and should be wrapped starting at the distal end of the limb and gradually wrapped upward, requiring the same pressure gradient as the compression stocking/cuff.
Ordinary compression stockings can be considered, but special care should be taken not to have elastic loops at the proximal end of the stocking to avoid too much pressure at the proximal end, which would instead interfere with venous reflux. The elasticity of the proximal end should be such that one finger can be inserted into the stocking. Elevation of the affected limb should be performed before compression therapy to ensure the return of retained fluid to the limb as much as possible. Sequential compression therapy can be used with caution in the late stages of DVT and in the case of stable thrombosis.
3.Exercise therapy of the distal limb of thrombosis site without resistance active contraction activity, especially isometric contraction exercise, is conducive to promoting venous return through the action of muscle pump. Commonly used exercises include: ankle flexion and extension exercise, quadriceps isometric contraction exercise (tense thigh), fist clenching exercise, etc. Unresistant bicycle or hand crank exercises also have clear value. Exercise therapy is generally not performed at an early stage to avoid thrombus dislodgement and resulting embolism. When performing muscle contraction, slow and continuous movements are emphasized to increase the safety of exercise.
4.Manipulation therapy DVT into the late stage or recovery period, in the case of clinical judgment of thrombus stability, the technique of lymphatic massage can be used, that is, centripetal massage from distal to proximal end. The manipulation must be gentle and superficial, and deep and forceful manipulation is contraindicated.
5, anticoagulation and thrombolytic therapy thrombolytic therapy has a history of several decades, with positive efficacy, but there are still debates on some specific issues, and the treatment method needs to be continuously researched and improved.
6.Inferior vena cava filter placement takes the femoral vein on the healthy side or the internal jugular vein on one side (in the case of bilateral lower limb lesions) as the access route, and places the filter in the inferior vena cava below the lower edge of the opening of the renal vein to prevent the thrombus from dislodging from the affected limb and the embolus from going up the blood flow and causing embolism of the important organs. Other surgical approaches are also available.
7.Risk factor control often use upright position to avoid blood volume reduction; drink enough water to ensure reasonable blood volume; prevent constipation to avoid elevated intra-abdominal pressure; prohibit intravenous infusion in the thrombosed limb; prohibit pulsatile pressure therapy and deep massage in the thrombosed unstable limb.