What are the next steps for a child in physical therapy with vein discomfort, not bone issues?

Management of Venous Discomfort in a Child Already in Physical Therapy

For a child experiencing venous discomfort who is already in physical therapy, a multidisciplinary approach involving vascular specialists is strongly recommended as the next step in management, as physical therapy alone is insufficient for addressing venous pathology.

Diagnostic Evaluation

• A referral to pediatric hematology or a pediatrician in consultation with a hematologist is recommended as they are best suited to evaluate complex venous issues in children 1
• Imaging assessment should be performed to determine if the child has deep vein thrombosis (DVT) or postthrombotic syndrome (PTS), which commonly presents with venous discomfort 1
• Venous ultrasound is the first-line imaging modality for suspected venous issues, with MR venography or CT venography as secondary options for more complex cases 2

Understanding Postthrombotic Syndrome (PTS) in Children

• PTS is a common complication following DVT in children, with studies showing it affects 32-49% of children with prior DVT 1
• The most commonly reported symptoms in children with PTS include:
  • Pain (55% of cases)
  • Impaired endurance (50%)
  • Limb tiredness (49%)
  • Limb heaviness (40%)
  • Swelling (36%) 1
• PTS severity directly impacts quality of life - for every point increase in PTS severity score, global functioning scores decrease by 0.2 points and happiness scores decrease by 0.3 points 1

Management Options

Anticoagulation Assessment

• If DVT is confirmed, anticoagulation therapy should be initiated as recommended by the ASH/ISTH guidelines 1
• For children with symptomatic DVT, anticoagulation is suggested rather than no anticoagulation (conditional recommendation) 1
• The choice between low-molecular-weight heparin or vitamin K antagonists should be based on the child's specific circumstances and family preferences 1

Venoactive Medications

• The role of venoactive medications in treating venous symptoms in children is currently unknown, as no studies have investigated their use in pediatric patients with venous issues 1
• A multidisciplinary approach to pain management may be required for persistent venous symptoms 1

Physical Therapy Modifications

• While the child is already in physical therapy, the therapy should be modified to specifically address venous issues 1
• Although no specific studies address exercise training for pediatric venous issues, evidence from adults suggests that targeted exercises to increase leg strength, flexibility, and overall fitness may improve venous-specific quality of life 1
• Physical therapy should focus on exercises that promote venous return and reduce venous congestion 1

Compression Therapy

• Compression therapy should be considered as an adjunct to physical therapy for managing venous symptoms 3
• Properly fitted compression garments can help reduce venous congestion and improve symptoms 3

Special Considerations

• Vascular anomalies may be contributing to venous symptoms and should be evaluated by appropriate specialists 4
• Pediatric vascular issues often require a different approach than adult cases, with medical therapies frequently utilized rather than invasive interventions 5
• For children with central venous catheter-related thrombosis, evaluation of catheter function and potential removal may be necessary if it's contributing to venous symptoms 1

Follow-up Recommendations

• Regular follow-up assessments should be scheduled to monitor symptom progression and treatment response 1
• If symptoms persist despite conservative management, referral to a pediatric vascular surgeon may be warranted to evaluate for more advanced interventions 5
• Ongoing assessment of quality of life and functional status is important, as venous issues can significantly impact a child's overall well-being 1