Clinical Inquiries

Should patients with acute DVT limit activity?

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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).

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.1-6 They 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.8 Patients 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

SubjectsStudy groupsResults
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 subsidedAt 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 stockingsNo 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 2No difference in PE
102 patients with DVT, treated with LMWH, compression4 Bed rest for 5 days AmbulationNo 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 DVT2,7 Ambulation and use of firm, inelastic Unna boot bandages Ambulation and elastic compression stockings Strict bed rest for 9 days and no compressionNo 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 groupNo difference in DVT, PE, phlebography results, or calf circumference
DVT, deep vein thrombosis; LMWH, low-molecular-weight heparin; PE, pulmonary embolism.

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