Don’t just lie down in bed, get moving: Prevention of deep vein thrombosis in the lower extremities

Author: Zhu Congcong Xuanwu Hospital, Capital Medical University

Reviewer: Kou Jingli, Chief Nurse, Xuanwu Hospital, Capital Medical University

There may be a special group of people around us who have almost no outdoor activities and are easily forgotten and ignored by this society. They are bedridden patients. Clinically, bedridden patients are defined as those who carry out activities to maintain basic physiological needs (eating, excretion, etc.) in bed, except for standing by the bed or sitting in a wheelchair for examination, treatment, etc. Due to long-term bed rest, their daily activities are reduced, venous blood flow is stagnant, and they may be combined with risk factors that easily induce hypercoagulable state such as advanced age, obesity, and tumors. The probability of deep vein thrombosis in the lower limbs of bedridden patients is greatly increased.

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So what is deep vein thrombosis? What are its dangers?

Deep vein thrombosis (DVT) refers to the abnormal coagulation of blood in the deep vein lumen, causing complete or incomplete blockage of the blood vessels. It is a venous reflux disorder that can occur in the main veins of the body, especially in the lower limbs.

DVT generally has no obvious symptoms and is easily ignored by patients. Symptomatic patients mainly show pain and swelling in the affected limb. A few patients will experience increased skin temperature and skin color changes in the limbs, accompanied by symptoms such as increased body temperature and increased heart rate. If not discovered in time and treated actively, severe cases may cause pulmonary embolism, which is life-threatening. Pulmonary embolism has an extremely high mortality rate and is a well-deserved "silent killer". In addition, as the disease progresses, post-thrombotic syndrome may occur due to thrombosis in the later stage. Studies have reported that 20% to 50% of DVT patients may develop post-thrombotic syndrome after 2 years, of which 5% to 10% of patients have severe symptoms, including pain, swelling, heaviness, itchy skin, cramps and lameness in the affected limb, ulcers and ulcers on the skin of the limbs. Symptoms vary from person to person, sometimes intermittently, sometimes continuously, usually aggravated after standing or walking for a long time, and gradually alleviated after resting or raising the limbs. However, since bedridden patients are unable to get out of bed for a long time, or are even in a coma or have speech disorders or abnormal limb motor function, many of their symptoms are easily masked, which greatly increases the probability of patients developing DVT without knowing it.

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So in order to reduce the incidence of DVT and prevent bedridden patients from suffering from the pain caused by DVT, what should patients and their families do?

In fact, for bedridden patients, the simplest and most beneficial exercise to prevent DVT is ankle pump exercise.

Ankle pump exercise is to strengthen the function of calf muscle pump by simulating the contraction and relaxation function of lower limb muscles such as quadriceps femoris, anterior and posterior tibialis, soleus, gastrocnemius, peroneus long and short muscles through active ankle dorsiflexion and plantar flexion during normal walking. In addition, the calf muscle pump is a crucial "pump" in the blood circulation of the lower limbs. Ankle pump exercise squeezes the veins through muscle activity and accelerates venous return, thereby preventing the occurrence of DVT. In addition, there are many venous sinuses with the function of storing venous blood and venous valves that prevent venous return in the veins of the calf muscles. When patients are bedridden for a long time, blood stagnates in the venous sinuses, the oxygen concentration in the venous valves decreases, and hypoxia induces the expression and release of inflammatory mediators in endothelial cells, further increasing the risk of thrombosis. In addition, slow blood flow can induce a surge in the number of platelets, and the coagulation factors in the blood are in contact with the venous wall for a longer time and adhere to the vascular wall, inducing the occurrence of DVT.

Since ankle pump exercises have "big benefits", let's quickly start doing these "small moves" to prevent lower limb DVT!

The first movement - ankle flexion and extension exercise: within the range of no pain or slight pain, bend your toes upward as far as possible, with your toes facing yourself, hold for 3 to 5 seconds, then bend your toes downward as far as possible, hold for 3 to 5 seconds. The above movements are a set, and the legs can be performed alternately or simultaneously.

The second movement - ankle joint rotation: perform 360° ankle joint rotation with the ankle joint as the center.

Exercise frequency: ankle flexion and extension exercises 3 to 4 times a day, 20 to 30 sets each time. The frequency of ankle circumference exercises is the same as that of flexion and extension exercises. The exercise frequency can be adjusted appropriately according to the patient's activity tolerance.

Ankle pump exercises are so good, can all bedridden patients do them?

The answer is no. No matter how good ankle pump exercise is, it has its scope of use. For example, the following people are not suitable for ankle pump exercise: ① limbs have thrombosis; ② femoral vein has intravenous catheter; ③ pathological fracture, ankle fracture has not healed and has not been internally fixed; ④ ankle instability caused by various other reasons; ⑤ previous exercise caused injury, pain, inflammation aggravated, also need to stop training.

If bedridden patients are unable to move independently, their primary caregivers can assist them with passive activities to increase their activity levels. Studies have shown that although active exercise is more effective than passive exercise, active ankle pump exercise will produce a very obvious sense of fatigue due to contraction of the calf muscles. Relatively speaking, passive exercise will be more comfortable, so patients will be more compliant with exercise.

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What can we do to improve compliance with voluntary ankle pump exercises in bedridden patients?

(1) Increase the intensity of scientific education and publicity to make more people understand the dangers of deep vein thrombosis in the lower limbs and enhance patients' awareness of the disease.

(2) The action demonstration should be simple and easy to operate, so that patients can master the key points of the action faster and better.

(3) Encourage the primary caregiver at home to supervise the patient's exercise, for example, by using a timer or alarm clock to ensure that the patient completes the exercise task on time and in the right amount, and give the patient encouragement after completing the task.

(4) To avoid fatigue, patients can exercise moderately each time and avoid long-term and extensive exercise. Try to choose a time period when the patient can rest after sufficient rest or after activities, such as after getting up in the morning, after a nap, and before going to bed.

A study on ankle pump exercise compliance found that pain after exercise is the main factor affecting patient compliance. If bedridden patients experience pain after exercise, they can consult a doctor through the Internet or in-person medical consultation to find the cause of the pain. After eliminating exercise contraindications, they can adjust the amplitude or frequency of exercise to relieve the pain. If necessary, they can use painkillers as prescribed by the doctor.

In addition to ankle pump exercises, what other ways are there to prevent DVT?

(1) The lower limbs of bedridden patients can be raised 20 to 30 cm above the level of the heart, and hard pillows should be avoided under the knees and excessive hip flexion should be avoided.

(2) If the underlying disease allows, bedridden patients can be encouraged to drink plenty of water, 1500 to 2500 ml of water per day. This can not only avoid hemoconcentration caused by dehydration, but also increase urine volume and reduce the risk of urinary tract infection.

(3) Improve your lifestyle, quit smoking and drinking, eat a balanced diet, and control your weight, blood sugar, and blood lipid levels.

(4) Depending on the patient’s recovery, get out of bed and move around as soon as possible.

(5) You can choose suitable "elastic stockings" to prevent DVT. Before use, measure the size of the bedridden patient's lower limbs according to the product instructions and choose the appropriate type of elastic stockings. If the patient can tolerate the elasticity of the elastic stockings, it is recommended to wear them day and night and take them off intermittently.

Whether you are a bedridden patient or the primary family caregiver, you need to be vigilant about the occurrence of deep vein thrombosis in the lower extremities. I hope that every patient will not lie flat in bed and do the "small movements" of ankle pump exercises to truly achieve "big benefits".

References:

[1] Chinese Society of Orthopaedics. Guidelines for the prevention of venous thromboembolism in major orthopaedic surgery in China[J]. Chinese Journal of Orthopaedics, 2016, 36(2): 65-71.

[2] Chinese Nursing Association. Preventive nursing care for venous thromboembolism in adult hospitalized patients: CNAS 28—2023 [S/OL]. http://hltb.kxj.org.cn/uploads/admin/202301/63d8f42928ec9.pdf

[3] Gu Siqi, Kong Dan, Li Jiahui, et al. Research progress on the hemodynamic mechanism and application of ankle pump exercise in preventing deep vein thrombosis[J]. West China Medical Journal, 2023, 38(7): 1096-1099.

[4] Ma Yufen, Cheng Shouzhen, Liu Yilan, et al. Expert consensus on nursing care for common complications in bedridden patients[J]. Chinese Journal of Nursing Management, 2018, 18(6): 740-747.