Acute Deep Vein Thrombosis: Early Mobilization Does not Increase the Frequency of Pulmonary Embolism

Abstract

SummaryOutpatient treatment for acute symptomatic deep vein thrombosis (DVT) was shown to be safe for most patients. However, little is known whether patients treated on an outpatient basis were ambulating or predominantly resting, a factor which may be decisive for the outcome. In the present study 129 DVT patients were randomized to either strict immobilization for 4 days or to ambulate for ≥4 hours per day under supervision in order to show, whether the old concept of temporary immobilization is superior to early mobilization or not. The DVT diagnosis was based on duplex sonography; all patients were screened for PE at baseline and at day 4 by pulmonary ventilation-perfusion scanning, and were followed up for a total of 3 months. Clinically, changes in leg circumferences and leg pain were evaluated. The frequency of PE at baseline was 53.0% and 44.9% in the immobile and the mobile groups, respectively. During the 4 days observation period new PEs were found in 10.0% and in 14.4% of the immobilized and the ambulating patients (Δ 4.4%; 95% CI −0.5 to 13.8; χ2 = 0.596, p = 0.44). The occurrence of new PE was related to the presence of PE at baseline but not to other potential predictors. The magnitude of a decrease in leg circumferences and leg pain was comparable in both groups. No patient died during the 4 day observation period. The total 3 month mortality rate was 3.9% (5 patients; 2 from the immobile, 3 from the ambulating group). All 5 patient suffered from malignancies. The results of this study show in accordance with the trial hypothesis that, regarding the frequency of PE, immobilization is not superior to early mobilization, suggesting that early mobilization is safe.

Does supervised exercise after deep venous thrombosis improve recanalization of occluded vein segments? A randomized study

“…This concept and safety of early ambulation/exercise is also supported by other studies of walking exercises [29,30], and by randomized studies showing no increased frequency of sub clinically scintigraphically detected PE in patients that had early mobilisation compared to bedrest [4,7]. Our study is limited due to the low number of patients included, but while no substantial benefit was seen from exercise regarding recanalization, no obvious complications could be attributed to early exercise either.…”

“…Initial bed-rest is still a part of DVT treatment at many centres [3]. However, this treatment strategy in DVT has been critically questioned [4][5][6][7][8]. Additionally randomized studies have shown that the incidence of scintigraphically detectable PE is not reduced by bed-rest in the treatment of DVT [4,7].…”

“…However, this treatment strategy in DVT has been critically questioned [4][5][6][7][8]. Additionally randomized studies have shown that the incidence of scintigraphically detectable PE is not reduced by bed-rest in the treatment of DVT [4,7]. Instead bed-rest has been shown to promote thrombus progression [8][9][10].…”

Myths and Legends in Orthopaedic Practice: Are We All Guilty?

“…One prospective study examined 126 patients with acute proximal DVT randomized to strict bed rest and elevation or early mobilization and found no difference in the incidence of pulmonary embolus as detected by lung scintigraphy [113]. Two other prospective, randomized trials comparing bed rest with immediate mobilization reported walking made no difference on the incidence of pulmonary emboli [9,97], and in one study, early mobilization promoted considerably faster resolution of leg pain and swelling [97]. Finally, a large prospective cohort examined 1289 consecutive patients with acute DVT treated with lowmolecular-weight heparin, oral anticoagulation, and immediate stocking compression and ambulation and found a low complication rate with this approach leading the authors to recommend their algorithm as safe, effective, and superior to bed rest [96].…”

Ambulation after Deep Vein Thrombosis: A Systematic Review

“…7 However, this assumption has never been tested empirically. 6,8,9 A conservative treatment approach of bed rest can lead to secondary complications and can thus be detrimental for patients, as acknowledged by Dock in 1944. 10 The impact of prolonged immobility was also noted by an English pathologist who identified an increase in the incidence of fatal PE in individuals seated in cramped underground shelters for prolonged periods during World War II.…”