Should patients with acute DVT limit activity?

,; Stevermer, James; ,

Clinical Inquiries

Should patients with acute DVT limit activity?

J Fam Pract. 2010 January;59(1):50-52

By

Rola Saab, MD

James J. Stevermer, MD, MSPH

Susan Meadows, MLS

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References

1. Aschwanden M, Labs KH, Engel H, et al. Acute deep vein thrombosis: early mobilization does not increase the frequency of pulmonary embolism. Thromb Haemost. 2001;85:42-46.

2. Blattler W, Partsch H. Leg compression and ambulation is better than bed rest for the treatment of acute deep venous thrombosis. Int Angiol. 2003;22:393-400.

3. Isma N, Johanssson E, Bjork A, et al. Does supervised exercise after deep venous thrombosis improve recanalization of occluded vein segments? A randomized study. J Thromb Thrombolysis. 2007;23:25-30.

4. Junger M, Diehm C, Storiko H, et al. Mobilization versus immobilization in the treatment of acute proximal deep venous thrombosis: a prospective, randomized, open, multicentre trial. Curr Med Res Opin. 2006;22:593-602.

5. Romera A, Vila R, Perez-Piqueras A, et al. Early mobilization in patients with acute deep vein thrombosis: does it increase the incidence of symptomatic pulmonary embolism? Phlebology. 2005;20:141.-

6. Schellong SM, Schwarz T, Kropp J, et al. Bed rest in deep vein thrombosis and the incidence of scintigraphic pulmonary embolism. Thromb Haemost. 1999;82(suppl 1):127-129.

7. Partsch H, Kaulich M, Mayer W. Immediate mobilisation in acute vein thrombosis reduces post-thrombotic syndrome. Int Angiol. 2004;23:206-212.

8. Trujillo-Santos J, Perea-Milla E, Jimenez-Puente A, et al. Bed rest or ambulation in the initial treatment of patients with acute deep vein thrombosis or pulmonary embolism: findings from the RIETE registry. Chest. 2005;127:1631-1636.

9. Partsch H, Kechavarz B, Kohn H, et al. The effect of mobilisation of patients during treatment of thromboembolic disorders with low-molecular-weight heparin. Int Angiol. 1997;16:189-192.

10. Partsch H. Therapy of deep vein thrombosis with low molecular weight heparin, leg compression and immediate ambulation. Vasa. 2001;30:195-204.

11. Martin M. PHLECO: a multicenter study of the fate of 1647 hospital patients treated conservatively without fibrinolysis and surgery. Clin Invest. 1993;71:471-477.

12. Buller HR, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126 (suppl 3):401S-428S.

13. Snow V, Qaseem A, Barry P, et al. Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2007;146:204-210.

EVIDENCE-BASED ANSWER

PROBABLY NOT. Ambulation, combined with compression of the affected extremity, appears to be safe for medically stable patients with deep venous thromboses (DVT) (strength of recommendation [SOR]: A, consistent randomized controlled trials [RCTs]). Leg compression and ambulation, compared with bed rest without compression, can effectively decrease swelling and pain (SOR: A, consistent RCTs).

Only weak data exist to suggest that early ambulation can reduce mortality (SOR: C, cohort studies with historical controls).

FAST TRACK

Ambulation, along with compression of the affected extremity, appears to be safe for medically stable patients with DVT.

Evidence summary

Patients with acute DVT have traditionally been treated with immobilization and bed rest, combined with anticoagulation, for days. This approach is motivated by fear of dislodging an unstable thrombus and causing a pulmonary embolism (PE) and by the belief that inactivity relieves local pain and swelling. On the other hand, bed rest promotes stasis, an element in Virchow’s triad.

Early ambulation doesn’t raise risk of PE
We performed a structured literature review, which found 6 RCTs and 3 cohort studies that address this problem. All 6 RCTs included patients with acute DVT but without life-threatening conditions.^1-6They assessed various outcomes, including incidence of new PE, change in leg circumference, leg pain, patient well-being, and progression of DVT.

The studies consistently found that early ambulation, along with compression, is safe when compared with bed rest ( TABLE ). Although the sample size of all the RCTs was small, the RCTs showed consistent trends in favor of ambulation and compression.

A prospective cohort study of new PE in patients treated with ambulation and compression plus anticoagulation found that the incidence of PE was significantly lower than historical incidence rates in patients managed with bed rest.⁷

Another study using the RIETE registry, a Spanish registry of consecutively enrolled patients with objectively confirmed acute DVT or PE, found no significant difference in occurrence of new PE between immobilized and mobilized patients.⁸Patients with DVT who were immobilized were generally sicker, more likely to have PaO₂ <60, and more likely to have received lower doses of low-molecular-weight heparin (LMWH) compared with the group that walked (P<.005).

TABLE
Early ambulation and compression: What RCTs show

Subjects	Study groups	Results
129 patients with DVT, treated with LMWH¹	Strict immobilization for 4 days Ambulation for ≥4 h/d, along with compression for 4 days or until swelling subsided	At 4 days: No difference in PE, leg pain, leg size, mortality At 3 months: No difference in PE, mortality
146 patients with DVT, all anticoagulated⁵	Hospital treatment with 5 days of bed rest Home care with early walking and compression stockings	No difference in occurrence of new PE after 10 days
126 patients with DVT, treated with LMWH, compression⁶	Strict bed rest for 8 days with leg elevation Began full ambulation on day 2	No difference in PE
102 patients with DVT, treated with LMWH, compression⁴	Bed rest for 5 days Ambulation	No differences in PE, thrombus progression, serious adverse events, or leg pain Study didn’t recruit expected number of patients Study showed a trend toward benefit from ambulation
53 patients with DVT^2,7	Ambulation and use of firm, inelastic Unna boot bandages Ambulation and elastic compression stockings Strict bed rest for 9 days and no compression	No difference in quality of life or PE DVT-related symptoms, leg pain, and circumference improved in compression/ambulation groups No changes noted at 2 years
72 patients with DVT, treated with anticoagulation and compression³	Daily walking exercise and weekly group exercise Control group	No difference in DVT, PE, phlebography results, or calf circumference
DVT, deep vein thrombosis; LMWH, low-molecular-weight heparin; PE, pulmonary embolism.

Evidence-based answers from the Family Physicians Inquiries Network