What are the guidelines for occupational therapy for occlusive deep vein thrombosis (DVT) in the left axillary, mid brachial, distal brachial, and basilic veins?

Occupational Therapy Guidelines for Upper Extremity Deep Vein Thrombosis

For patients with occlusive deep vein thrombosis in the left axillary, mid brachial, distal brachial, and basilic veins, occupational therapy should be initiated only after appropriate anticoagulation therapy has been established, with early mobilization preferred over bed rest to improve outcomes related to morbidity, mortality, and quality of life. 1

Initial Medical Management (Prior to OT Intervention)

Anticoagulation must be initiated before occupational therapy begins:

• Therapeutic anticoagulation is indicated for upper extremity DVT that involves the axillary or more proximal veins (Grade 1B) 2
• Preferred anticoagulants include:
  • LMWH (e.g., enoxaparin) or fondaparinux over IV or SC unfractionated heparin (Grade 2C) 2
  • DOACs (rivaroxaban, apixaban) may be considered as alternatives 1
• Duration of anticoagulation:
  • Minimum 3 months for upper extremity DVT (Grade 2B) 2
  • If catheter-related, anticoagulation should continue as long as the catheter remains in place 2

Occupational Therapy Protocol

Phase 1: Acute Management (Days 1-7)

1. Positioning and Elevation

   • Elevate affected arm when at rest to reduce swelling
   • Avoid dependent positions that may increase venous pressure

2. Early Mobilization

   • Begin gentle active range of motion exercises within pain tolerance
   • Avoid exercises that cause pain or significant discomfort
   • Encourage functional use of unaffected limbs for ADLs

3. Edema Management

   • Monitor for signs of increasing edema
   • Light massage proximal to distal may be used if not contraindicated

Phase 2: Subacute Management (Weeks 2-4)

1. Progressive Mobilization

   • Gradually increase range of motion exercises
   • Begin light resistance exercises as tolerated
   • Incorporate functional activities that involve the affected arm

2. Compression Therapy

   • For patients who develop post-thrombotic syndrome (PTS) of the arm, compression bandages or sleeves are suggested to reduce symptoms (Grade 2C) 2
   • Note: For acute symptomatic upper extremity DVT, compression sleeves are not routinely recommended (Grade 2C) 2

3. Activity Modification

   • Teach energy conservation techniques
   • Modify activities to avoid prolonged arm positioning above heart level
   • Avoid activities with high risk of trauma while anticoagulated 1

Phase 3: Functional Rehabilitation (Weeks 5-12)

1. Progressive Strengthening

   • Gradually increase resistance exercises
   • Focus on functional movements needed for work, leisure, and self-care

2. Return to Activities

   • Gradual return to normal activities with modifications as needed
   • Educate on signs of recurrence or complications

Important Considerations and Precautions

• Contraindications to Therapy:

  • Unstable anticoagulation status
  • Acute pulmonary embolism
  • Severe pain or significant increase in swelling during activity

• Monitoring During Therapy:

  • Observe for signs of bleeding (bruising, petechiae)
  • Monitor for increased swelling, pain, or discoloration
  • Assess for signs of post-thrombotic syndrome

• Activity Guidelines:

  • Encourage regular physical activity while receiving appropriate anticoagulation 1
  • Avoid activities with high risk of trauma while anticoagulated 1
  • Stay well-hydrated during exercise 1

Long-term Management

• Regular assessment for post-thrombotic syndrome
• Continued use of compression garments if PTS develops
• Venoactive medications are not recommended for PTS of the arm (Grade 2C) 2

Pitfalls to Avoid

1. Premature Aggressive Therapy: Beginning aggressive therapy before adequate anticoagulation increases risk of clot dislodgement and pulmonary embolism.

2. Neglecting Compression Therapy: If PTS develops, failure to implement compression therapy can worsen symptoms and functional outcomes.

3. Overlooking Psychological Impact: Upper extremity DVT can cause anxiety about arm use; address psychological barriers to movement.

4. Inconsistent Follow-up: Regular monitoring is essential to detect complications early and adjust therapy accordingly.

The evidence specifically addressing occupational therapy for upper extremity DVT is limited, but these guidelines synthesize the available evidence on anticoagulation management 2 and general activity recommendations 1 to provide a framework for occupational therapy intervention that prioritizes patient safety while promoting functional recovery.