Hypercoagulation is an issue in asymptomatic, pre-symptomatic, and other active COVID-19 cases, as well as in those who have recovered from the virus. Emergency Medical Services, those who respond to 911 calls, provide us with some guidance about how to screen for blood clots.((Estreicher, M., Hranjec, T., & Pepe, P. E. (2020, May 16). Spotting the clotting: Hypercoagulopathy in COVID-19. EMSWorld. Retrieved from https://www.emsworld.com/article/1224381/spotting-clotting-hypercoagulopathy-covid-19. When first accessed, registration was not required.)) Here are some other things to watch for:

1. Anyone with circulatory disease (diabetes, hypertension) may be at risk for hypercoagulopathy.
2. It may manifest in the heart and lungs as “chest tightness that may be positional in nature or change with deep respirations even in the face of normal oxygen saturations.”
3. The usual leg pain or swelling indicates veinous involvement. Arterial clots manifest as a lost pulse in the extremity “with or without associated pain, discoloration, or loss of motor/sensory function.”
4. Neurological deficits can include stroke, “presentation of confusion or altered mental status,” or “changes in smell or taste.”
5. “Strange rashes, hematomas, petechiae, and purpura (bruise-like findings…)” not normally seen on a regular basis. Also “reddened conjunctiva, erythematous skin blotches, and strawberry-colored tongue appearance”
6. Diarrhea and abdominal cramping, tender abdomen can all be a sign of clotting in the abdomen (vessels supplying the intestines).
7. Flank pain can indicate issues in the kidney.

These items can be added to our screening protocols.

Ruth Werner, a massage therapy pathology expert, has been following this issue closely.

She has developed a series of questions to ask those who have recovered from COVID-19.((Werner, R. (2020, June 1). Questions for clients who have had COVID-19. Associated Bodywork & Massage Professionals. Retrieved from https://www.abmp.com/updates/blog-posts/questions-clients-who-have-had-covid-19)) See Questions For Clients Previously Diagnosed with  COVID-19” (https://www.abmp.com/updates/blog-posts/questions-clients-who-have-had-covid-19)

And in a recent article, Werner provided more information based on her conversation with a hematologist.((Werner, R. (2020, July 16). COVID-related coagulopathy, take 3: A conversation with a hematologist. Associated Bodywork & Massage Professionals. Retrieved from https://www.abmp.com/updates/blog-posts/covid-related-coagulopathy-take-3-conversation-hematologist?fbclid=IwAR0MWuy8PwUJySwa5ct9VDSMqedObjnu7HSEDbwEDD7eawrhleVt5Ikw7Jk))

Information from that article includes:

• The questions she developed for a previous article were affirmed by the hematologist and he would add screening for signs and symptoms of DVT.
• About the Disease:
  • “Body-wide, uncontrolled coagulation… is rarer in mild to moderate cases”
  • We don’t know how long the risk of blood clotting problems remain after a person recovers from the virus. We also don’t know how common these problems are for those who were infected but not hospitalized.
  • Differentiation between COVID and other conditions:
    • Deep muscle and joint pain can be due to rhabdomyolysis, hypoxia, or microvascular thrombosis. If the latter two, “gentle massage is likely to be safe”. If it’s rhabdo, “the pain is likely to be both extreme and localized, and there would also likely be urinary symptoms.” If that’s the case, refer out. Kimmet note: And do so immediately. Rhabdo can be a life threatening issue.
• Understanding Medications
  • • • If prescribed for a short term course (30 days), this is usually a preventative measure. If prescribed for 3 months or more, this indicates someone who may have been identified with clotting problems. Kimmet Note: this can provide some discernment on whether you are comfortable continuing with treatment
• Impacts for Treatment:
• • • If signs of DVT, refer out immediately. If there are only signs in the skin (isolated bruises, rashes, bumps, discoloration, etc.), the risk of embolism is lower. Thus gentle massage is “unlikely to cause any greater disruptions”.
    • “Work[ing] especially lightly” to avoid bruising is appropriate for those on medications (anticoagulants or blood thinners). Kimmet note: This was also true in pre-COVID days.
    • “Work[ing] especially lightly over skin lesions like rashes or petechiae” is appropriate.