Latest / European Society for Vascular Surgery / Get Moving: How Exercise Impacts Deep Vein Thrombosis- with M. J. van Rijn

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Get Moving: How Exercise Impacts Deep Vein Thrombosis- with M. J. van Rijn · European Society for Vascular Surgery

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  Each year, between 50 to 100 adults per 1 ,000
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  experience a first episode of symptomatic deep
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  vein thrombosis. The mortality rate for venous
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  thromboembolism is about 10 % at 30 years and
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  22 % in the first year. Welcome to the ESVS Podcasts.
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  Today, we are going to discuss the role of exercise
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  in DVT with Dr. Marie José Van Rijn. Dr. Marie
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  José Van Rijn is a vascular surgeon at Erasmus
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  University Medical Center in Rotterdam, Netherlands.
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  Her main clinical and research interests include
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  deep vein thrombosis, post -thrombotic syndrome,
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  complex arterial disease, and advanced wound
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  care. Van Rijn is also a section... also section
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  editor of venous and lymphatic disease for the
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  european journal of vascular and endovascular
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  surgery she was part of the writing committee
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  for the 2022 esvs guidelines on chronic venous
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  disease is co -editor of the dutch phlebology
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  textbook and board member of the Benelux Society
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  of Phlebology and European Venous Forum. Dr.
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  Mirzen, thank you very much for joining us. Thank
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  you for having me and for the very kind introduction.
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  Let's start talking about DVT. The standard treatment
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  of acute DVT, as our listeners know, is anticoagulation,
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  compression therapy and early mobilization. The
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  ESVS guidelines recommend both anticoagulation
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  and compression therapy as a class 1, level A
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  recommendations. And for the great majority of
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  patients, outpatient management is also a class
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  1, level A recommendation. But this wasn't always
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  the case. When I started practice 20 years ago,
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  patients were prescribed strict bed rest to avoid
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  thrombus progression and pulmonary embolism.
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  What does the evidence tell us today about the
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  risk of thrombus progression in patients who
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  walk after a DVT? It's a very important question
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  because indeed that has definitely changed when
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  you compare to earlier days. The evidence actually
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  shows that there is no risk, no increased risk
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  of pulmonary embolism or progression of the DVT.
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  It actually... diminishes the progression of
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  DVT. So it actually helps to get the deep veins
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  re -canalized. So it's very important to tell
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  the patients to mobilize early and not keep them
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  in bed. Let's say to our patients to move. And
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  there are any clinical scenarios where bed rest
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  remains advisable? What do you think? I actually
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  don't think there are any scenarios where you
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  should pay. put patients into bed. No, I think
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  they should just always be advised to start walking
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  around as soon as they can. Perfect. We know
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  that you and your research group published a
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  systematic review last year in the Journal of
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  European Academy of Thermatology and Venerology.
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  exploring the effects of exercise following a
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  deep vein thrombosis. We will include the reference
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  in our show notes if our listeners want to read
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  your paper. And in this review, you analyzed
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  physical activity based on timing and duration,
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  categorizing the findings into three groups.
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  early mobilization during the acute phase of
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  DVT, short duration exercise during one year
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  post -DVT, and prolonged exercise during long
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  -term follow -up after DVT. Is there evidence
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  that early mobilization or exercise can improve
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  acute DVT symptoms such as edema or pain? Yeah,
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  so it was quite a difficult analysis and the
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  reason for that is that in all of these studies,
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  different outcomes are being used. So it's difficult
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  to compare studies and we couldn't do any meta
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  -analysis, for example. That's the main problem
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  overall for studies on post -thrombotic syndrome,
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  for example, in DVT studies. But what we did
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  find is that the early mobilization in the acute
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  phase after DVT improved quality of life. and
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  led to pain reduction. And after two years, it
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  resulted in a significant reduction of PTSD severity.
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  There is a clinical improvement. I would like
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  to know the importance of compression therapy
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  during exercise. Does the compression therapy
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  improve the benefits of exercise? Yeah. We think
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  so. Again, not much evidence, not much studies
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  that have been looking at this specifically.
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  But there has been studies done, of course, to
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  see the effect of compression therapy after a
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  DVT. And some studies show that, again, also
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  for the compression, it increases the recanalization.
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  And there have been studies done in people performing
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  sports activities, and they also show that there
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  is a benefit of wearing compression stockings.
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  Again, it's very difficult when you don't use
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  the same outcomes. and when sometimes you have
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  to wait longer to find the real effects and studies
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  have sometimes quite a short follow -up and then
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  it's hard to find significant differences, of
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  course. So we should use compression therapy?
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  That would definitely be my suggestion, yes.
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  Perfect. Let's talk a little bit about post -thrombotic
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  syndrome. We know that PTS is a common complication
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  of DVT, affecting 20 to 50 % of patients one
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  or two years after the diagnosis. We and our
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  listeners know the clinic of PTS, so severe pain,
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  leg heaviness, and in severe case, the patients
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  can have venous ulceration. PTS impacts patients'
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  quality of life. and the health care system.
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  Simple interventions such as the exercise, the
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  focus of this podcast may reduce post -thrombotic
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  syndrome severity and improve the quality of
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  life. What did your systematic review found about
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  the effect of the exercise on PTS and quality
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  of life? Yeah, well, first of all, it found that
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  that there was no increase on the risk of PTSD
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  or worsening of symptoms due to physical activity,
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  because that is a main problem in itself. Of
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  course, when you had a DVT and you start walking,
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  then at first it can actually hurt. And that
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  is for a lot of patients, but also for physicians,
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  a trigger to say that they should stop exercising
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  because it's painful, probably it's bad, and
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  they're doing something wrong. And none of the
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  studies showed that. So it is, even though it
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  does indeed sometimes increase pain while exercising
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  and even also swelling of the leg, that is not
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  harmful and it in the end will benefit. So you
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  have to explain to the patients, it's like the
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  same for arterial disease, right? You have to
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  accept that there is some pain, but that will
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  in the end benefit. So we found that specifically,
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  like I said, if you mobilize early on after a
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  DVT. Then there was a significant reduction of
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  PTS severity in the long term, so after two years.
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  But also studies didn't specifically look at
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  PTS, but for example, looked at joint mobility
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  or pain. So again, a comparison between the studies
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  was difficult. Such those outcomes, not specifically
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  PTS like measured with falalta, but also again.
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  They found, most of the studies found that there
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  was a benefit from mobilization after a DVT.
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  Also after a little while after DVT, maybe even
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  when you already have PTS. Okay, fantastic. Talking
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  a little bit about the physiology, we know that
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  exercise increased the fibrinolytic activity
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  and reduced inflammation. And we know that the
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  decrease in inflammation and enhancement in thrombolysis
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  are critical mechanisms for vein recanalization,
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  which helps to prevent post -thrombotic syndrome.
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  The question is, are there any other physiopathological
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  mechanisms or physiological mechanisms that explains
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  the improvement of quality of life and PTSD?
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  after exercise? Yeah, well, there has been some
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  mouse studies done that looked at resistance
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  exercise, for example, and they found also again
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  here an increased recanalization rate, but they
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  also found that pro -inflammatory factors decreased.
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  So it has a sort of anti -inflammation effect.
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  In addition, when you exercise, Yeah, you, of
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  course, train the muscles. And I mean, this is
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  all not studied very extensively, like into the
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  tissue itself. But like for arterial disease,
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  you can imagine that if you exercise a lot, then
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  you first of all, you know, get more used to
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  also the fact that there is more stasis of blood.
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  You know, there is more of this venous hypertension
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  and there are going to be collaterals formed.
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  And you see that. significantly when you look
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  at patients over time, when we follow them up
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  on the outpatient clinic, you see that, for example,
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  a palma vein, which is a crossover vein, the
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  pubic region, when there is a single -side ilic
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  vein obstruction, you see that palma vein increase.
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  So you just actually try to mobilize, you know,
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  collateral pathways to get the blood out of the
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  leg. If you challenge the leg while exercising,
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  yeah. And that is, like I said, it's not... it's
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  not studied into that depth and that we actually
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  did biopsies for example to see what is really
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  happening but you do see a clinical improvement
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  of the leg while you see it swelling down and
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  specifically the increase of the collaterals
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  are very noticeable okay so the the increase
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  in collaterals is an important point okay yes
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  definitely perfect let's go to practical points
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  what specific types of and intensities of exercise
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  like aerobic resistance treadmill what are the
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  most important exercise to improve the dvd symptoms
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  is daily walking enough or do you recommend strength
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  or resistance exercise what exercise you recommend
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  to your patients yeah i start mainly by telling
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  I'm telling them to just walk because that is
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  easy to do, can be done everywhere and always.
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  And it's not difficult. You don't need to go
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  anywhere for that. You don't need to go to a
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  gym. And you can ask patients to track their
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  amount of steps every day. So that is what I
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  just tell them. Nothing fancy, not difficult.
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  Just go and walk and try to get your 10 ,000
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  steps in every day, which I know already is a
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  lot. But the other thing I always try to find
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  out is what do the patients really like to do?
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  If you want to get a patient motivated, you need
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  to find the things that they like to do the most.
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  So I have patients that really love, for example,
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  strength training. And I just tell them to start,
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  see if this works for them, if they can still
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  do it. Sometimes when I do squats, for example,
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  they do get more pain because you build up, of
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  course, more pressure in the abdomen when you
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  do the squats. And it sometimes can be painful.
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  So I'm not sure for every patient if this is
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  a good exercise to do, but I just tell them,
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  try it. And the main thing is that over the next
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  days, you would still be able to exercise. So
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  if you do any sports that, you know, throws you
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  off for like a week, then of course that is not
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  helpful because I think it's better to do something
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  every day or every other day than just once a
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  week. Okay, but you also mentioned an important
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  topic that is the endurance to exercise. That's
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  I think it's important. Yes, to motivate our
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  patients. Now we are going to talk a little bit
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  about recommendations. The American Heart Association
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  emphasizes the role of supervision exercise.
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  So the American Heart Association recommends
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  supervised exercise for PTS patients combining
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  leg strength training and aerobic activity for
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  at least six months. This is a recommendation
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  class 2A. level B of evidence. So are there any
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  European recommendations on this topic? No, it
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  was not in the ESVS guidelines, unfortunately.
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  I would really hope that there's going to be
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  a recommendation in there for the next guidelines.
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  Okay, we are almost finishing. I would like to
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  know if you have any advice or final remarks
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  to our listeners on this topic. Well, I think
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  for me, the most important thing is the awareness
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  that exercising is important for patients that
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  have a DVT in acute phase, but also if the patient
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  already has post -thrombotic syndrome. But because
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  we can do a lot of invasive therapies at the
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  moment, and that is very nice, of course, that
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  we can do this. But sometimes I feel that the
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  more easy steps to take, the more conservative
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  measures have not really been tried in fullest.
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  So patients didn't really get good compression
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  therapy and were not told to exercise. And sometimes
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  my patients come in and they come in to, you
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  know, get some advice on whether or not they
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  could be standard, for example. And then we start
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  first with exercising. And then they improve
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  a lot and then we don't even need to do an invasive
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  treatment. And they are just, you know, very
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  happy also that they can do something themselves
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  instead of that we as doctors are going to put
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  stents in them. And not that I'm saying that's
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  wrong because like, yeah, that is something I
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  do a lot. But I really like this, like when I
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  see my patients getting so excited and coming
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  back and saying, I have improved my number of
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  steps and I feel so much better and so much healthier.
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  So just to know that you cannot do anything wrong
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  with that, that helps also to tell the patient
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  that because they're sometimes just very, very
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  worried because they feel this pain and they
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  think they're doing something wrong. Okay, that's
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  a really... Good advice for us. So, I hope today's
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  conversation with Dr. Mercedes van Rijn has reinforced
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  just how important exercise is for our patients.
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  Thank you for listening to the ESVS podcasts.
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  Don't forget to follow us on Spotify, SoundCloud,
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  Apple Podcasts and through the ESVS library.
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  And if you found this episode helpful, please
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  share it with your colleagues. Until next time.
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  stay active and stay curious yeah definitely
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  see you there bye bye