Should a patient with Deep Vein Thrombosis (DVT) be immobilized or mobilized?

From the Guidelines

Patients with Deep Vein Thrombosis (DVT) should be mobilized early rather than immobilized, provided they are receiving appropriate anticoagulation therapy. Early mobilization is now the standard of care for most DVT patients, as it helps prevent complications like muscle atrophy and deconditioning, improves quality of life, and does not increase the risk of pulmonary embolism when proper anticoagulation is maintained 1.

Key Considerations for Mobilization

• Patients should begin walking as soon as pain allows while taking prescribed anticoagulants such as low molecular weight heparin (e.g., enoxaparin 1mg/kg twice daily), direct oral anticoagulants (e.g., rivaroxaban 15mg twice daily for 21 days followed by 20mg daily), or warfarin (target INR 2-3) 1.
• Compression stockings providing 30-40 mmHg pressure at the ankle should be worn during ambulation to reduce swelling and pain.
• The historical practice of strict bed rest was based on unfounded concerns about clot dislodgement.
• However, patients with massive DVT causing severe pain or significant limb swelling may require brief periods of elevation and limited activity until symptoms improve.
• Additionally, patients should be educated to avoid prolonged standing or sitting in one position and to stay well-hydrated during recovery.

Prevention of Venous Thromboembolism

• Intermittent pneumatic compression (IPC) in addition to routine care is recommended over routine care to reduce the risk of deep vein thrombosis (DVT) in immobile stroke patients without contraindications 1.
• Low-molecular weight heparin (i.e. enoxaparin) should be considered for patients with acute ischemic stroke at high risk of venous thromboembolism; or unfractionated heparin for patients with renal failure 1.
• Early mobilization and adequate hydration should be encouraged for all acute stroke patients to help prevent venous thromboembolism 1.

From the Research

Treatment Approach for Deep Vein Thrombosis (DVT)

• The treatment of DVT is based on anticoagulation with heparin, warfarin, and direct oral anti-coagulants 2.
• According to the 9th ACCP Recommendation, for patients with DVT of the lower limbs, where the clinical state and home conditions permit, preference is given to home treatment over hospitalization 2.

Mobilization vs. Immobilization

• Randomized and observation studies have shown faster relief from pain and swelling in patients keeping to the regimen of early mobilization wearing compression means, compared to patients keeping bed rest, while the incidence of new cases of PE was the same for both groups 2.
• A prospective, randomized, open, multicentre trial found that mobilization versus immobilization in the treatment of acute proximal deep venous thrombosis showed no benefit of prescribing bed rest in patients with deep venous thrombosis 3.
• The study found that 7 of 52 patients (13.5%) in the mobile group versus 14 of 50 patients (28.0%) in the immobile group suffered at least one of the outcomes defined under the combined primary endpoint 3.

Importance of Compression and Walking Exercise

• Compression and walking exercise is essential in the acute phase of the disease, which, along with internal thrombolytic mechanisms of the body, accelerates recanalization and development of the collateral blood vessels in the deep muscular compartment of the lower limb 2.
• Graduated compression stockings or the use of a pneumatic compression device, and administration of the correct dose of anticoagulation agent (heparin or LMWH) can prevent DVT 4.

Prevention of Post-Thrombotic Syndrome (PTS)

• Prevention of DVT is the only effective approach to PTS prevention, as PTS is not reliably prevented by treatment of the initial DVT with anticoagulant therapy or thrombolysis 5.
• Pharmacological thromboprophylaxis prevents venographically proven DVT in patients following orthopedic surgery, and is now recommended by North American and European consensus statements 5.