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)

Meadows, Susan E.

Saab, Rola

Stevermer, James J.

University of Missouri: MOspace

Evidence-based answers from the Family Physicians Inquiries Network50 THE JOURNAL OF FAMILY PRACTICE  |   JANUARY 2010  |   VOL 59, NO 1patients treated with ambulation and com-pression plus anticoagulation found that the incidence of PE was signifi cantly lower than historical incidence rates in patients managed with bed rest.7Another study using the RIETE registry, a Spanish registry of consecutively enrolled patients with objectively confi rmed acute DVT or PE, found no signifi cant diff erence in occurrence of new PE between immobi-lized 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). Does ambulation affect thrombus propagation?A multicenter RCT showed that thrombus pro-gression occurred more often in patients who were treated with bed rest compared with pa-tients treated with ambulation and compres-sion (P<.01).2 Another RCT revealed a similar trend, though the diff erence didn’t reach statistical signifi cance because of small sample size.4 Th e clinical importance of these phlebographic studies isn’t clear.   Should patients with acute DVT limit activity? Evidence summaryPatients with acute DVT have traditionally been treated with immobilization and bed rest, combined with anticoagulation, for days. Th is approach is motivated by fear of dislodg-ing an unstable thrombus and causing a pul-monary 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 PEWe performed a structured literature review, which found 6 RCTs and 3 cohort studies that address this problem. All 6 RCTs in-cluded 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. Th e studies consistently found that early ambulation, along with compression, is safe when compared with bed rest (TABLE). Al-though 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 EVIDENCE-BASED ANSWERA probably not. Ambulation,  combined with compression of the aff ected extremity, appears to be safe for medically stable patients with deep venous thromboses (DVT) (strength of recommen-dation [SOR]: A, consistent randomized controlled trials [RCTs]). Leg compression and ambulation, compared with bed rest without compression, can eff ectively de-crease swelling and pain (SOR: A, consis-tent RCTs). Only weak data exist to suggest that ear-ly ambulation can reduce mortality (SOR: C, cohort studies with historical controls). Rola Saab, MD; James J. Stevermer, MD, MSPH; Susan Meadows, MLSDepartment of Family and Community Medicine, University of Missouri, Columbia (Drs. Saab and Stevermer); and Department of Family and Community Medicine, University of Missouri, Columbia (Ms. Meadows)Ambulation, along with compression of the affected extremity, appears to be safe for medically stable patients with DVT.50_JFP0110   50 12/21/09   12:06:08 PM51JFPONLINE.COM VOL 59, NO 1  |  JANUARY 2010  |  THE JOURNAL OF FAMILY PRACTICEIs it the walking,or compression, that works?RCTs have shown that ambulation with leg compression, compared with bed rest with-out compression, can eff ectively decrease leg swelling and pain1,2,4 Th e diff erence was de-tectable 2 years after DVT.7 In contrast, RCTs in which both ambulat-ing and resting patients received compression therapy showed no signifi cant diff erence in leg circumference at 1 or 6 months.3 Th is fi nding suggests that the benefi t on local symptoms may result from compression rather than am-bulation.Reduced mortality? Evidence is weakEstimates of the possible eff ect on mortality of ambulation compared with bed rest are based on cohort studies. A cohort study in which 691 patients were kept walking with compression therapy reported a mortality rate of 0.2%.9 In another cohort, the mortality rate was also 0.2%, and all deaths occurred in patients older than 70 years.10 Th is rate is lower than rates reported in the historic literature, which typically are 1% among patients treated with unfractionated heparin and bed rest.9,10 A retrospective, multicenter co-hort of 1647 patients treated with unfractionated TABLEEarly ambulation and compression: What RCTs showSubjects Study groups Results129 patients with DVT, treated with LMWH1Strict immobilization for 4 daysAmbulation for ≥4 h/d, along with compression for 4 days or until swelling subsidedAt 4 days:    No difference in PE, leg pain, leg size, mortalityAt 3 months:   No difference in PE, mortality146 patients with DVT, all anti-coagulated5Hospital treatment with 5 days of bed restHome care with early walking and compression stockingsNo difference in occurrence of new PE after 10 days 126 patients with DVT, treated with LMWH, compression6Strict bed rest for 8 days with leg elevationBegan full ambulation on day 2No difference in PE102 patients with DVT, treated with LMWH, compression4Bed rest for 5 daysAmbulation No differences in PE, thrombus progression, serious adverse events, or leg painStudy didn’t recruit expected number of patientsStudy showed a trend toward beneﬁ t from ambulation53 patients with DVT2,7 Ambulation and use of ﬁ rm, inelastic Unna boot bandagesAmbulation and elastic compression stockingsStrict bed rest for 9 days and no compressionNo difference in quality of life or PEDVT-related symptoms, leg pain, and circumference improved in compression/ambulation groupsNo changes noted at 2 years72 patients with DVT, treated with anticoagulation and compression3Daily walking exercise and weekly group exerciseControl groupNo difference in DVT, PE, phlebography results, or calf circumferenceDVT, deep vein thrombosis; LMWH, low-molecular-weight heparin; PE, pulmonary embolism.Compression may be the key factor in reducing leg pain and swelling.51_JFP0110   51 12/21/09   12:06:12 PM52heparin and bed rest in diff erent German hospi-tals reported a rate of fatal PE of 2.33%.11Data from the RIETE registry indicated that overall mortality was signifi cantly higher in immobilized patients with a PE (3.6% vs 0.5% in mobile patients; P=.01).8 Notably, im-mobilized patients with a PE were more likely to be hypoxic and also tended to receive lower doses of LMWH. No diff erences were found in outcomes for patients with DVT. RecommendationsTh e American College of Chest Physicians (ACCP) doesn’t recommend bed rest in its guidelines for treating acute venous thrombo-embolism, but rather ambulation as tolerated after starting anticoagulation. Patients who are not hemodynamically stable should be stabilized fi rst. Th e ACCP also recommends wearing an elastic compression stocking with a pressure of 30 to 40 mm Hg at the ankle for 2 years after an episode of DVT and a course of intermit-tent pneumatic compression for patients with severe edema of the leg resulting from post-thrombotic syndrome.12 A joint guideline from the American Col-lege of Physicians and the American Academy of Family Physicians doesn’t make recom-mendations about ambulation for therapy of DVT and PE.13 1.  Aschwanden M, Labs KH, Engel H, et al. Acute deep vein throm-bosis: early mobilization does not increase the frequency of pul-monary embolism. Th romb Haemost. 2001;85:42-46. 2.  Blattler W, Partsch H. Leg compression and ambulation is better than bed rest for the treatment of acute deep venous thrombosis. Int Angiol. 2003;22:393-400.  3.  Isma N, Johanssson E, Bjork A, et al. Does supervised exercise af-ter deep venous thrombosis improve recanalization of occluded vein segments? A randomized study. J Th romb Th rombolysis. 2007;23:25-30.  4.  Junger M, Diehm C, Storiko H, et al. Mobilization versus immobi-lization in the treatment of acute proximal deep venous thrombo-sis: a prospective, randomized, open, multicentre trial. Curr Med Res Opin. 2006;22:593-602.  5.  Romera A, Vila R, Perez-Piqueras A, et al. Early mobilization in patients with acute deep vein thrombosis: does it increase the incidence of symptomatic pulmonary embolism? Phlebology. 2005;20:141.  6.  Schellong SM, Schwarz T, Kropp J, et al. Bed rest in deep vein thrombosis and the incidence of scintigraphic pulmonary embo-lism. Th romb Haemost. 1999;82(suppl 1):127-129. 7.  Partsch H, Kaulich M, Mayer W. Immediate mobilisation in acute vein thrombosis reduces post-thrombotic syndrome. Int Angiol. 2004;23:206-212.  8.  Trujillo-Santos J, Perea-Milla E, Jimenez-Puente A, et al. Bed rest or ambulation in the initial treatment of patients with acute deep vein thrombosis or pulmonary embolism: fi ndings from the RIE-TE registry. Chest. 2005;127:1631-1636.  9.  Partsch H, Kechavarz B, Kohn H, et al. Th e eff ect of mobilisation of patients during treatment of thromboembolic disorders with low-molecular-weight heparin. Int Angiol. 1997;16:189-192.  10.  Partsch H. Th erapy of deep vein thrombosis with low molecular weight heparin, leg compression and immediate ambulation. Vasa. 2001;30:195-204. 11.  Martin M. PHLECO: a multicenter study of the fate of 1647 hos-pital patients treated conservatively without fi brinolysis and sur-gery. Clin Invest. 1993;71:471-477.  12.  Buller HR, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Th rombolytic Th erapy. Chest. 2004;126(suppl 3):401S-428S. 13.  Snow V, Qaseem A, Barry P, et al. Management of venous throm-boembolism: a clinical practice guideline from the American Col-lege of Physicians and the American Academy of Family Physi-cians. Ann Intern Med. 2007;146:204-210.ReferencesData on the effect of early ambulation on mortality are weak.THE JOURNAL OF FAMILY PRACTICE  |   JANUARY 2010  |   VOL 59, NO 1This activity was presented by the Warren Alpert Medical School of Brown University and supported by educational grants from Astellas Pharma US, Inc., and Pﬁ zer Inc.FREE 1.0 CME CREDITClick on CME/Supplements/Newsletters at jfponline.com. Or, visit www.jfponline.com/supplements.asp?id=7976.Frequently asked questions in the evaluation and management of overactive bladderPatients often do not ask for medical help for overactive bladder (OAB) due to social stigma, misconceptions that OAB is an inevitable consequence of aging, and fear that the assessment and treatment will be more troublesome than the symptoms themselves.A panel of 4 experts discuss the prevalence and pathophysiology of OAB, the role of behavioral and pharmacologic therapies, and how to recognize when referral to a urologist is appropriate.Pamela I. Ellsworth, MDStephen A. Brunton, MDAlan J. Wein, MD, PhD (Hon)Eric S. Rovner, MD••••AN EXPERT PANEL INTERVIEW52_JFP0110   52 12/21/09   12:06:16 PM

Should patients with acute DVT limit activity?

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