JOURNAL CLUB: VENOUS THROMBOEMBOLISM RETURN TO PLAY

Date and Time: Tuesday September, 29 at 18:00

Presenter: Dr. David Lawrence – Sports and Exercise Medicine Fellow
Title: Athletes and Venothromboembolism – Managing return to play
Location: Goldring Centre – MacIntosh Clinic 3rd floor presentation room

Articles Reviewed:

Roberts WO1, Christie DM Jr. Return to training and competition after deep venous calf thrombosis. Med Sci Sports Exerc. 1992 Jan;24(1):2-5.

Depenbrock PJ1. Thromboembolic disorders: guidance for return-to-play. Curr Sports Med Rep. 2011 Mar-Apr;10(2):78-83. doi: 10.1249/JSR.0b013e318214d828.

Presentation:

Subject: Answers to outstanding questions from Tuesdays Journal Club on DVT and VTE in athletes

Hematologists -	CK	BG	AM
1) What duration of anticoagulation would you recommend for athletes that have had an unprovoked DVT?	At least 3 months. Possibly, post trauma proph prn	For unprovoked DVT/PE –> indefinite anticoagulation with yearly review of this decision. Don’t do thrombophilia testing (has no treatment implications – just causes harm). Don’t do serial imaging to see if the clot is gone (total waste of resources and also no impact on treatment).	When it comes to duration I don’t think there is any reason to manage athletes differently than others. Duration of anticoagulation always comes down to provoked or unprovoked. For unprovoked we worry more if a male, more as people get older. However for first unprovoked event it really comes down to risks vs benefits. If the anticoag will have a very negative effect on lifestyle eg. all my hockey players…. then that has to be part of the decision. Sometimes also depends on event for a lifethreatening PE requiring thrombolysis I have few pts who come off anticoag. Unprovoked otherwise healthy active 50 yr old male….up to them as long as they understand the risks.
2) What point do you consider it safe for athletes to return to running after DVT? Contact sports? ) Resistance training?	If on anticoags; depends on the trauma. May resume resistance training at any time, depending on symptoms	Return to running as soon as they feel able to – the sooner the better. The key is to do it gradually, not for physical reasons but the athlete will be distraught if they can’t do what they think they should be able to. We want their health self-confidence (which has taken a huge hit) to gradually return.Depends on the contact sport. No for rugby, mixed martial arts with mutual assault, competitive football, competitive hockey, boxing. No restriction for non-high level hockey. Competitive soccer a concern re small intracranial bleeds. Skiing anytime. Basketball, tennis, etc as soon as they feel up to it.Resistance training right away.Risk of embolization goes away within a few days and no evidence that enforced reduced activity reduces this risk.I tell athletic patients to take it easy this week (walk, other cardio OK) and then ramp up to usual acitivities as they tolerate.We want to avoid making a healthy person with a clot into someone who’s disabled or very nervous perhaps forever. Every week, i see a lot of harm done by well-meaning health providers who give patients bad advice.	General exercise I tell pts start slow see how leg feels build up gradually. This will be slower for big clots but no exact time and we encourage to start as soon as possible. Contact sports…if on anticoag I stress the risk of bleeding and use of helmets some listen some don’t.
3) Are you aware of any effect on exercise on preventing or inducing effect of Post thrombotic syndrome?	Exercise should not aggravate PTS in anyway. May want to wear stockings as may be helpful.	Weak evidence for exercise treating the anatomic causes of PTS but: (a) patients with DVT who are paralyzed resolve their DVT more slowly or not at all; (b) exercise elaborates endogenous t-PA from the leg endothelium which might help; (c) physical symptoms and reduced health self-confidence resolve more quickly with progressive return to exercise; (d) it’s an essential component of treatment if someone has PTS.	No, only good study on PTS I know is the SOX trial which was negative I am not totally up on the sports literature though.
4) We take care of a number of professional athletes, who often suffer injuries then have to travel long-hours on return. Would you recommend prophylactic anticoagulation (NOACs) in patients with lower limb trauma that have to travel?	Probably not.	Travel advice depends on situation. If patient is anticoagulated, no risk to travel. If they had a provoked DVT/PE and the provoking factor now gone, little or no risk to travel. If they are anxious about travel, offer them rivaroxaban 10 mg on the day of a cross-ocean flight (there’ll NEVER be evidence but might be effective and makes everyone more comfortable abotu this). For someone who’s injured, depends on the injury and when it was. If a major LE injury, would prophylax.	Travel we usually worry about long haul flights > 8 hrs. If a pt has had a previous VTE then more worried. If you thought the injury had risk of VTE eg. Crush or very swollen and not worried about bleeding then yes would be appropriate. We use rivaroxaban (Xarelto) now for this 10 mg or I use 15 as I have those samples in my office.
Does really intense exercise INCREASE risk of DVT?		I think it does and have certainly seen very fit marathoners or intrense cyclists with DVT. There is a bit of literature on this but it has not been studied very well.