942
Pulmonary Embolism in Rehabilitation Patients: Relation to
Time Before Return to Physical Therapy After Diagnosis of
Deep Vein Thrombosis
Thomas S. Kiser, MD, Vikki A. Stefans, MD
ABSTRACT. Riser TS, Stefans VA. Pulmonary embolism in
rehabilitation patients: relation to time before return to physical
therapy after diagnosis of deep vein thrombosis. Arch Phys Med
Rehabil 1997;78:942-5.
Objective: There is increased risk of a pulmonary embolism
(PE) after a deep vein thrombosis (DVT). The effect of mobiliz-
ing the affected lower extremity has not been well studied. The
purpose of this study was to detect any change in the rate of
PE occurrence dependent on time to mobilization in patients
diagnosed with a DVT in a rehabilitation hospital.
Design: Retrospective case-control study.
Setting: Urban rehabilitation hospital.
Patients: Data were collected from charts of 190 patients
with a discharge diagnosis of PE or DVT at an urban rehabilita-
tion hospital from January 1991 to June 1995; 127 patients met
inclusion criteria in the study.
Interventions: Measurement of time to return to physical
therapy after diagnosis of DVT.
Main Outcome Measures: A DVT was diagnosed with ei-
ther Doppler ultrasound or venogram testing, a PE by ventila-
tion/perfusion (V/Q) scan, and time to mobilization in hours
until return to physical therapy.
Results: One hundred twenty-one patients had a DVT with-
out a subsequent PE and a mean time of 123.2 hours until
mobilization. Six patients had a subsequent PE and a mean time
of 48.3 hours until mobilization (p = .021). A Fischer exact
test comparing patients with and without PE who were returned
to therapy before 48 hours and after 48 hours (p = .018), and
before and after 72 hours @ = .059), supports the hypothesis
that patients who return to physical therapy earlier are more
likely to develop a PE than patients who return later.
Conclusions: It is imperative to prophylactically treat all
patients at risk of a DVT with anticoagulation if possible. Once
a DVT is diagnosed it is prudent to keep the affected limb
immobilized for at least 48 to 72 hours while the patient is
being anticoagulated. A large prospective cohort study is needed
to answer the question of when to mobilize a patient after diag-
nosis of a DVT.
0 1997 by the American Congress of Rehabilitation Medicine
and the American Academy of Physical Medicine and Rehabili-
tation
From the Department of Physical Medicine and Rehabilitation, University of
Arkansas for Medical Sciences, Little Rock, AR.
Submitted for publication September 6, 1996. Accepted in revised form January
20, 1997.
Presented as a poster at the American Academy of Physical Medicine and
Rehabilitation Annual Assembly in Chicago, October 12, 1996.
No commercial party having a direct financial interest in the results of the
research supporting this article has or will confer a benefit upon the authors or
upon any organization with which the authors are associated.
Reprint requests to Thomas S. Kiser, MD, Department of Physical Medicine
and Rehabilitation, 4301 West Markham, Slot 602A. Little Rock, AR 72205.
0 1997 by the American Congress of Rehabilitation Medicine and the American
Academy of Physical Medicine and Rehabilitation
0003-9993/97/7809-4178$3.00/O
Arch Phys Mad Rehabil Vol78, September 1997
DEEP VEIN THROMBOSIS (DVT) in the rehabilitation
A setting can be a major setback for a patient and can delay
functional recovery. It has been a standard practice to cease all
ambulation and range of motion (ROM) to the affected lower
extremity to avoid breaking the thrombus away from the
veins intimal lining, thereby causing a pulmonary embolus
(PE). This enforced bed rest puts most active rehabilitation on
hold and often results in transfer to an acute care hospital for
treatment. Although the biomechanical argument makes sense,
the duration and extent of risk of a PE via this mechanism is
actually unknown.
Caprini et al3 studied the rate of normalization of DVT after
diagnosis with serial Doppler ultrasound testing and reported
that a floating thrombus on initial exam in 18 vein segments
(25% of all thrombi) took an average of 10.7 days (range 2 to
33 days) to stabilize. Berry et al: in a similar study, reported
an incidence of 16% for floating thrombus and a 9.2-day
stabilization time on serial duplex exam. Francis, in response
to a letter asking for guidelines on when to mobilize a patient
after a DVT, recommended bed rest for 1 to 3 days with appro-
priate medical management, and return to ambulation on day 3
or 4, once pain and swelling were resolving, with return to full
activities in 2 to 4 weeks. Partsch et al6 studied 139 consecutive
ambulatory patients with DVT (80 with PE by V/Q scan on
admission) who were not placed on bed rest and ambulated
with 40 to 5OmmHg compression bandages applied to the af-
fected leg in an effort to fix free floating thrombi7. Eleven
(7.9%) patients developed a new PE on repeat V/Q scan after
11 days and one patient died from a PE 2 days after admission,
but had been ambulating for 2 weeks before admission. The
authors argue that this is the same incidence as in patients
treated with conventional bed restymi2and that mobilizing the
patient was no more dangerous than bed rest.13Brandstater et
alI4 in their literature review of DVT in stroke recommend
active rehabilitation measuresin bed progressing to gait training
and other active therapies once the partial thromboplastin time
(PTT) is in the therapeutic range.
The above recommendations are generally based on personal
experience and anecdotal evidence without a rigorous case-
control or prospective cohort study to substantiate them. The
push for shorter and shorter stays in the hospital has forced the
medical community to treat DVT more aggressively and de-
crease the time the patient is allowed to stay in bed. With
todays concerns of cutting and containing costs, the issue of
bed rest versus mobilization after diagnosis of a DVT is im-
portant. If there is no difference in outcome it would be far
better to ambulate a patient earlier and continue rehabilitation
than to prolong the hospital stay with bed rest and/or unneces-
sary transfers to an acute care hospital for management. The
purpose of this study was to compare the occurrence of PE
among patients who were mobilized early versus the occurrence
of PE among patients who were mobilized later.
METHODS
Charts of 190 patients admitted to our rehabilitation facility
from January 1, 1991 to June 30, 1995 with the discharge ICD-
9 code of DVT (453.8) and/or PE (415.1) were reviewed. Data
 PULMONARY EMBOLISM IN REHAB PATIENTS. Kiser 943

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

Arch Phys Med Rehabil Vol78, September 1997

944 PULMONARY
Table 3: Subjects Stratified by Time to Remobilization
Time to Number
Remobilize Without PE 1%)
~48 hours 22 (17.3%)
48-72 hours 15 (11.8%)
>72 hours 84 (86.1%)
significant difference was lost when comparing the group held
out of therapy for 72 hours or less to the group that returned
to physical therapy in more than 72 hours @ = .059) (table 3).
None of the venograms or Duplex ultrasound exams mentioned
a floating thrombus.
DISCUSSION
The diagnosis of a DVT is a particular problem for the reha-
bilitation specialist who is attempting to improve patients mo-
bility and independence. The most conservative accepted
treatment has been bed rest with immobility of the affected limb
for 10 to 14 days. However, this puts the patient at risk for
further deconditioning and other perils of immobility. Also, the
economics of medicine encourage earlier and earlier discharges.
The results of this study suggest that there is an increased risk
of PE in patients who are aggressively mobilized less than 48
to 72 hours after diagnosis of a DVT.
There are several factors in this study that make interpretation
difficult:
1. Many cases and controls were excluded because they were
transferred out of the rehabilitation setting; their eventual
outcome is unknown. It is likely that they were treated
with anticoagulation and bed rest, and did not receive
physical therapy in the acute care hospital.
2. We were unable to determine the degree of immobility
and restrictions to mobility except for time to return to
physical therapy. We believe, however, that the time to
return to physical therapy was accurate to within 2 hours.
The time used was the time the order was taken off the
physicians order sheet by the unit clerk, and it was veri-
fied by the physical therapy billing records.
3. A large percentage (13.7%) had a PE without ever having
had a DVT diagnosed and were therefore excluded. This
points to the inherent difficulty of diagnosing a DVT or
PE 6*17on a clinical basis.
4. The possibility that the positive V/Q scan was a false-
positive in the PE cases, or a negative V/Q scan was a
false-negative in the non-PE cases.18
5. In the DVT subjects in this study there were multiple
primary diagnoses (table 1) and the risk and natural history
of DVT and PE may vary by diagnoses.
6. There was a marked difference in thromboprophylaxis be-
tween the non-PE (19.7%) and PE (0%) group, suggesting
that those without thromboprophylaxis are more likely to
develop PE than those who did receive prophylaxis.
A major area of concern or limitation is that, if V/Q scans
are done at the same time as the diagnosis of a DVT, a certain
portion of patients will also have a high probability V/Q scan
despite being asymptomatic for PE. Partsch et al6 reported a
positive V/Q scan in 58% of ambulatory patients with DVT,
with only 7.9% symptomatic for PE. Nielson et ali9 reported a
49% incidence of silent PE in patients with a diagnosis of DVT,
and Moser et al a 40% incidence. Thus, there is a possibility
that any PE diagnosed after DVT was already present but not
investigated until the patient became symptomatic. However,
symptomatic PE with major morbidity and mortality risk is of
greatest concern clinically and V/Q scans at diagnosis of DVT
are not common clinical practice.
Arch Phys Med Rehabil Vol76, September 1997
EMBOLISM IN REHAB PATIENTS, Kiser
A floating thrombus as seen by Caprini et al3 and Berry
Number et al4 was not noted on any of the Doppler ultrasound exams
With PE 1%) reviewed in this study. It was either not looked for in the ultra-
4 (3.1%) sound studies, was missed, or did not occur in this study sample.
0 (0%) Despite these problems, this study provides some valuable
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
fatal attack. None of the patients who developed a PE received
thromboprophylaxis, because they were believed to be at low
risk of a DVT, or it was contraindicated as in the subdural
hematoma and intracerebral hemorrhage cases. This points to
the need to aggressively provide prophylaxis for patients at
risk for a DVT, especially in the rehabilitation setting. In a
retrospective autopsy study of patients whose primary cause of
death was PE, Morgenthaler and Ryu* noted that only 22% of
patients were tested for DVT; in only 49% was the diagnosis
of PE considered; and in only 32% was PE correctly listed as
the cause of death. As Mose? succinctly stated in an editorial,
Massive, fatal PE can be the first symptom of extensive DVT.
Only prophylaxis can avoid such an event.
CONCLUSION
It is imperative that patients at risk of DVT receive thrombo-
prophylaxis, if it is not contraindicated. The possibility of in-
creasing the patients risk of a PE with early mobilization de-
serves a large cohort prospective study to fully answer the
question. Until that is done, clinicians must use their best clini-
cal judgment to determine when to return a patient with an
acute DVT to ambulation and physical therapy. At least 48 to 72
hours of bed rest would be prudent before return to mobilization.
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