"DON'T RUB THEIR LEGS!"

Um...I guess my question is if they're at such high risk for blood clots why don't they have sequential compression devices on? The only time you wouldn't want to is if there's evidence that a blood clot actually exists...

It depends on the patient. I've seen and assisted PTs who are massaging lower extremeties during ROM on residents with contractures. I have never seen any RN or therapist perform leg massage for any other reason.

We got the same advice back in the day when I was a student. Back then everyone with a DVT was on bedrest to avoid moving the clot along with muscle contractions. Now DVT's are treated as outpatients, with no activity restrictions, so I imagine the ban on leg-rubbing is outdated too.

If they are at risk for blood clots shouldn't they be on an anticoagulent?

I think the big difference is going to be massaging a leg versus doing a quick rub down with lotion. Light rubbing shouldn't cause complications.

LOL, I always worry about throwing a clot when getting a pedicure, Those girls just beat the tar out of my legs....

I sometimes rub the legs to make sure they don't have a DVT. I am not talking about a true massage but just a quick feel of the calves to make sure they are not hard, warm, swollen or tender to the touch. In the hospital there is no time to give anybody a massage, though I think it would be helpful for stress reducation and pain mgmt.

Is that once their anticoags are therapeutic? 'Cause I'm still seeing patients on bedrest until their INRs look good. Sometimes that can take a week, depending on the patient's response.

First of all why would it take a doctor's order to massage their legs. I would consider this well within the realm of nursing care or PT. I would think that I would have to put an order not to massage their legs not the other way around (or communicate nicely please massage their legs) if I wanted it.

The problem is that their is a lot of of voodoo around DVTs. What we used to do is leave people on bedrest while we heparinized them. Then we would put them on Coumadin and let the INR get therapeutic. Then we would stop the heparin and let them out of bed. What we came to understand is that there is no increased risk of DVT with mobilizing the patient. On the other hand the cost in debilitation of bed rest is high. The article in chest pretty much put this to rest:
Bed Rest or Ambulation in the Initial Treatment of Patients With Acute Deep Vein Thrombosis or Pulmonary Embolism* — CHEST
Furthermore the current guidelines for DVT treatment do not even mention bed rest.

Now on to the topic of massage indirectly. The initial though was that that ambulating would dislodge clots and cause more PEs which has been disproved. SCDs mimic the action of walking and are though to prevent DVTs not only through preventing vascular stasis but promoting natural anti-coagulation through endothelial activation. SCDs mimic massage (actually with pressures higher that you would normally get with massage). The evidence here is not as strong (a few studies such as this):
Compression and walking versus bed rest in the tre... [J Vasc Surg. 2000] - PubMed result
The few small studies suggest that its safe and again the fact that the DVT guidelines don't even address it suggests that its pretty safe. Now that's in a patient with know DVT.

Take the example given above. The patient does not have a know DVT. If they are at risk for a DVT they should be on Heparin or SCDs (or both). In this case its even safer than a patient with a DVT (which seems to be pretty safe).

Bottom line there is a lot of misconception about DVT. The guidelines for treatment are easily available. Outside of this making up problems that don't exist doesn't help anyone. If my patients wanted their legs rubbed I'd do it.

David Carpenter, PA-C