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Three Part Question

In [adults with an acute calf DVT] would [anticoagulation therapy] allow [immediate mobilisation]?

Clinical Scenario

You are referred a 55 year old woman for a mobility assessment. She was diagnosed with an acute calf DVT yesterday and started on anticoagulation therapy. Is it safe to complete a mobility assessment today?

Search Strategy

Medline; Cinhal; Embase ; AMED; Cochrane. [(DVT OR Deep vein thrombosis) AND (anticoagulation OR warfarin OR heparin OR fragmin OR dalteparin OR thrombin inhibitor OR argatroban OR bivalirudin OR dabigatran OR desirudin OR lepirudin OR direct oral anticoagulants or DOAC OR dabigatran OR apixaban OR edoxaban OR rivaroxaban) AND (mobility OR mobilisation OR walking OR ambulation)] LIMIT to English language and Human and 2010-2021 and Full text

Search Outcome

296 papers found of which 288 irrelevant, 4 unavailable and 1 of insufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Liu et al 2015 China	3114+ DVT patients. Of known data: Mean age 62, 46:54 F:M.	Meta-analysis	Occurrence of new PE; progression of DVT; DVT related deaths; remission of pain and oedema.	• Compared to bed rest, early ambulation of acute DVT with anticoagulation is not associated with increased incidence of new PE, progression of DVT or DVT related deaths • In patients with mod-severe initial pain, early ambulation can reduce pain.	• Sample sizes of studies small and largest study included had significant potential for bias. • Early ambulation defined as starting exercise within 3 days of diagnosis- i.e. not ‘immediate’ • Some studies measured symptomatic PE only- may have given false negatives • Excluded patients with detectable PE at inclusion so results can’t be applied to all DVT patients (especially proximal) • Analysed studies published 2001-2013, data may be older
Pillai and Raval 2014 USA	2785 DVT patients. Of the known data (88% of subjects): mean age >65, 46:54 F:M.	Literature review	Occurrence of new PE.	1) In anticoagulated patients with DVT, there is no significant difference in risk between ambulation and bed rest for development of PE, while ambulation carries other benefits. 2) There are cases of PE development in both cohorts so ongoing medical assessment advised. 3) Further studies of higher quality are needed to definitely address the issue.	• Only 1 data base searched. Search terms not comprehensive • Studies published 2000-2008. Data may be older. • Doesn’t critique studies fully but data were levels III-V on McMaster criteria • Not fully clear on type of DVT: proximal vein, isolated calf, upper extremity (catheter related or not)
Wells et al 2014 Canada	DVT patients. Unclear- presuming adults	Review of Cochrane reviews, meta-analyses, and RCTs	Description of DVT treatment. PTS development/ PTS symptoms	Relevant points: Postthrombotic syndrome (PTS) is a frequent complication of DVT. In active patients, wearing compression stockings not found to reduce risk of developing PTS, but can improve oedema and pain in acute stage of DVT and also reduce PTS symptoms if that develops.	• Review mostly concerning anti-coagulation, not focussing on mobilisation • Points of interest are from single studies only which are not critiqued.

Comment(s)

Further studies of higher quality are needed to answer the question definitively, but it appears practice now favours early mobilisation, compared to bed rest as was historically advised. Currently, it appears that whilst DVT patients are at heightened risk of PE, this risk is not increased by immediate/early mobilisation when anticoagulated. Some literature only refers to early mobilisation, however, which may not be the same as immediate mobilisation. Studies also don’t allow for differentiation between types of DVT. Outpatient treatment of DVT is now common and implies immediate ambulation to go about ADLs. It appears mobilisation can reduce DVT pain (though not oedema), but also carries many other benefits, whilst bed rest carries many other risks.

Clinical Bottom Line

Until further evidence is available, you can encourage and facilitate immediate mobilisation of DVT patients on anticoagulation. Encourage wearing of compression stockings which may reduce associated pain and oedema. Be mindful they still remain at the same heightened risk for developing PE.

References

1. Zhenlei Liu, Xixi Tao, Yuexin Chen, Zhongjie Fan, Yongjun Li Bed Rest versus Early Ambulation with standard anticoagulation in the management of deep vein thrombosis: a meta-analysis. PLOS One April 10, 2015 1-15
2. Anupama R. Pillai, MSN, and Jay S. Raval, MD Does early ambulation increase the risk of pulmonary embolism in deep vein thrombosis: A review of the literature. Home Healthcare Nurse June 2014; vol. 32 • no. 6; Pg 336-342
3. Philip S. Wells, MD, FRCP(C), MSc; Melissa A. Forgie, MD, FRCP(C), MSc; Marc A. Rodger, MD, FRCP(C), Treatment of Venous Thromboembolism JAMA. 2014:311(7):717-728.