When Can the Patient With Deep Venous Thrombosis Begin to Ambulate?

 Physical Therapy . Volume 84 . Number 3 . March 2004

(Kapan Pasien DVT [deep vein trombosis] dapat memulai merubah posisi tidur?)

Deep venous thrombosis (DVT) is a common problem among hospitalized patients,1 even those who receive prophylaxis.2 Patients undergoing total hip replacement have a 54% risk of developing DVT following the procedure if no methods of prophylaxis are used.2 Use of low-molecular-weight heparin prophylaxis reduces this incidence to 16%. Despite prophylaxis, 31% of patients undergoing total knee replacement develop DVT, and 27% of patients operated on for hip fracture develop DVT.2 Thromboembolic complications have been reported in 30% to 60% of patients following stroke.3 Deep venous thrombosis places the patient at risk for pulmonary embolism (PE), recurrent thrombosis, and postphlebitic syndrome.1,4 Up to 50% of patients with DVT involving the proximal deep veins of the lower extremity develop PE. Because the mortality rate for this condition is as high as 8% even with intervention, PE poses the greatest concern to the physical therapist and physician caring for the patient during initial management of the DVT, particularly in the hospital setting.3 Current medical management of patients with DVT includes the use of acute anticoagulation with heparin or low-molecular-weight heparin (LMWH) followed by long-term intervention with warfarin.5 The use of full-dose heparin has been shown to reduce the incidence of PE among patients with proximal DVT.4 Low-molecular-weight heparin demonstrated at least equal efficacy to heparin in multiple trials.6 In the past, patients with active DVT were placed on bed rest for periods up to 7 to 10 days due to the fear of PE among patients who remain active.7 The logical, if simplistic, argument was that vigorous movement of the involved limb would cause the proximal clot to “break off and travel to the lungs.” More recent practice has included earlier ambulation, but there has been reluctance to begin ambulation immediately after diagnosis and initial 

management of DVT. In practice, there appears to be no standard protocol for activity progression.  We sought evidence from the medical literature to inform the decision about the timing of ambulation for patients with DVT. We used PubMed to search for relevant primary studies on the issue of ambulation and DVT. Our search strategy consisted of using the National Library of Medicine’s Medical Subject Headings (MeSH) terms “venous thrombosis” or “thrombophlebitis” combined with the MeSH terms “early ambulation,” “walking,” or “exercise.” We limited the results of this search to clinical trials reported in English.

This search yielded 17 references, of which 2 references were judged to be primary clinical trials after a review of the abstracts. We also searched using the MeSH term “bed rest” combined with the MeSH terms “venous thrombosis” or “thrombophlebitis.” We also limited this search to clinical trials reported in English. This strategy yielded 3 additional primary clinical trials that we believed would be relevant to the question of ambulation in the setting of DVT. We also searched the bibliographies of previous articles on the topic of ambulation and DVT for other potentially useful studies. Reference to an article by Partsch et al from 1997 seemed pertinent, but on closer inspection, this cohort of patients appeared to be included in a larger cohort published later by the same investigators.8 We noted the recent “Evidence in Practice” article by Charles Ciccone that reviewed a number of abstracts pertaining to our question as part of a demonstration of search strategies.9 Each of these references was identified by our original search strategy.

get Full text PDF [klik here]