Bed rest versus ambulation in the initial treatment of patients
with proximal deep vein thrombosis
Hugo Partsch, MD
Partsch, H. Bed rest versus ambulation in the initial treatment of patients with proximal deep vein thrombosis. Curr Opin Pulm Medi. 2002; 8:389-393.
INTRODUCTION
Treatment for DVTs include low molecular weight
heparin (LMWH) and oral anticoagulants
In the past, physicians have recommended 4 to 5
days of bed rest for patients with a DVT
• Bed rest prescribed for fear of dislodging the clot
and causing a pulmonary embolism or death
• Resolution of pain and swelling are reasons for bed
rest
•
BED REST DOES NOT PREVENT PULMONARY EMBOLISM
• Two RCT’s show no significant differences between
the onset of new PEs and baseline lung scans if
patients are bedridden or ambulating with leg
compression.
– 1st study – early ambulation is safe for
patients with DVTs
– 2nd study – bed rest cannot reduce the
incidence of detectable PEs
• Partsch’s opinion on studies – minimal threat of
fatal PE if LMWH is used correctly and patients are
walking and using compression stockings
BED REST PROMOTES THROMBUS PROPAGATION
• Bed rest can increase risk of fatal PE due to venous
stasis and thrombus propagation.
• Patients who were able to ambulate within 2 days
had less thrombus propagation than patients who
were on bed rest for >5 days.
• An increase in the length of thrombus in the
femoral vein was found in patients on bed rest
without compression compared to patients who
ambulated with compression.
Katelyn Koeninger, Student Physical Therapist
Email: kkoeninger01@bellarmine.edu
RESEARCH POSTER PRESENTATION DESIGN © 2011
www.PosterPresentations.com
COMPRESSION AND WALKING LEAD TO A FASTER
REDUCTION IN PAIN AND SWELLING
• Reduction of pain and swelling was significantly
greater in patients who ambulated with compression
compared to patients who were on bed rest.
– Unna boot bandages and thigh length
compression stockings showed a significant
improvement in quality of life compared to
bed rest.
• Aschwanden et al. reported no differences in pain
scores or leg circumference between the bed rest
and ambulation groups.
– Pain during exercise was less in the
ambulation group after 4 days.
CLINICAL SIGNIFICANCE
• Physical therapists in the acute care setting
encounter patients with DVTs on a regular basis.
Guidelines are in place for PT departments that
usually include no ambulation for several days. This
article shows that keeping the ambulant patient
mobile with compression will not increase the risk
of PE and that ambulation can reduce pain and
swelling in the legs in patients with an acute DVT.
CONCLUSION
• Bed rest can be harmful when treating patients
AMBULATION AFTER DEEP VEIN THROMBOSIS:
A SYSTEMATIC REVIEW
Anderson C, Overend T, Godwin J, Sealy C, Sunderji A. Ambulation after
Deep Vein Thrombosis: A Systematic Reveiew. Physiotherapy Canada. 2009;
61:(3):133-140.
• Results: Comparing ambulation and compression to
bed rest alone for development of a new PE, results
favored the ambulation and compression group.
– Progression of a thrombus was evaluated
between several groups including the
ambulation and compression group vs bed
rest and compression. The results favored
the ambulation and compression group.
with an acute DVT due to venous stasis and
thrombus propagation.
• A combination of ambulation and compression
stockings is recommended treatment plan for
patients with DVTs after LMWH has been
administered.
Figure 3 Forest plot showing independent relative risk for progression or development of a
new DVT: ambulation and compression (A) vs bed rest alone (B)6 and bed rest and
compression (B)19.
BED REST OR AMBULATION IN THE INITIAL TREATMENT
OF PATIENTS WITH ACUTE DVT OR PE
Trujillo-Santos J, 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:(5):1631-6.
Mountanside-medical .com
PREVENTION OF VENOUS STASIS MAY IMPROVE LATE
OUTCOME
• Initial response to heparin in the first 24 hrs has
been a factor in the recurrence of DVTs in the
following 3 months. Ambulation in the first 24 hrs is
recommended to discourage venous stasis.
• Wearing appropriate compression stockings, not
taking long-term anti-coagulants, reduces the
frequency of post-thrombotic syndrome in patients
who have previously had a proximal DVT due to the
decreased occurrence of venous stasis.
• Results: No differences in the rate of PE between
the bed rest group (0.7%) and the ambulatory group
(0.4%). No differences found in the rate of a fatal
PE or major bleeding complications in the bed rest
or ambulatory group. However, minor bleeding and
overall mortality were significantly more common in
bedridden patients.
• Relevance to PT: Ambulation is no more dangerous
than bed rest for patients with DVTs. The same
results were found to be true of patients with
pulmonary embolism. Therefore, ambulation can be
initiated after the diagnosis of a DVT and even
possibly a PE, without fear of dislodging a clot.
• Relevance to PT: Bed rest is not beneficial for
patients with DVT since there is “no harm
associated with early ambulation in pts diagnosed
with a DVT.” During ambulation, pts should be
monitored closely for changes in status and clinical
judgment should be used when determining if
ambulation is appropriate.
– Early ambulation does not increase the risk
of developing a PE, progression of an
existing DVT, or developing a new DVT.
SUMMARY
• Previous treatment for acute DVTs included
anticoagulant therapy and bed rest. Recent
literature suggests no significant differences in new
PEs or clots being dislodged between bed rest and
ambulation groups.
• Pts with acute DVTs should begin ambulation with
compression immediately after LMWH is received to
prevent venous stasis and deconditioning.