Early Ambulation After Acute Deep Vein

Thrombosis: Is It Safe?

Marilyn Slavin Blumenstein, MSN, RN

The number of thrombotic events in children, vein thrombosis (DVT). Her staff had 4 questions:
although significantly less than that in adults, is (1) Is it correct to hold ambulation/out-of-bed orders
increasing as a result of therapeutic advances in pri- if there is a suspected DVT or if an ultrasound result
mary illnesses that were previously fatal. When a is pending? (2) Once a DVT is diagnosed and the
patient, adult or pediatric, develops a deep vein patient is placed on anticoagulant therapy using
thrombosis and anticoagulation therapy is initiated, enoxaparin (Lovenox®), how long until the patient is
many health professionals ask, “When should this out of bed and/or ambulating? (3) With DVTs, are
patient have physical therapy and/or ambulate?” bed exercises on the unaffected limbs allowed? (4)
Fear of causing a pulmonary embolism with Who is the point person for questions related to
increased activity drives this question. Often, an ambulation and physical therapy for patients with
order for bed rest is prescribed based more on tradi- DVTs? Questions like these are also asked by other
tion than on evidence-based medicine. A review of the health care providers who are responsible for the day-
literature has provided an evidence-based answer to to-day supervision and coordination of patient activi-
the question, and although the studies are all of adult ties. One-size-fits-all answers to these questions are
populations, the results have been extrapolated for unhelpful and potentially dangerous. The attending
use with comparable pediatric populations. The physician responsible for the patient, sometimes in
majority of studies agree that early ambulation does collaboration with a hematologist, is in the best posi-
not increase an anticoagulated patient’s risk for pul- tion to direct the patient’s care. Our pediatric physical
monary embolism. Moreover, most studies report that therapy manager was advised to continue to collabo-
early ambulation carries benefits such as decreased rate with the patient’s attending physician. In addi-
pain and swelling and fewer postthrombotic syn- tion, I conducted a literature search and evaluated the
drome symptoms. evidence-based clinical research concerning ambula-
tion in the setting of acute DVT. Those results were
Key words: deep vein thrombosis, ambulation, physi-
used to inform our practice and are offered here so
cal therapy, pulmonary embolism, children
that other pediatric nursing and physical therapy
groups can inform their practices too.

R ecently, a pediatric physical therapy manager

asked me for practice recommendations for her
staff when they are working with children with deep Marilyn Slavin Blumenstein, MSN, RN, is a thrombosis program nurse
coordinator at the Children’s Hospital of Philadelphia. Address for cor-
respondence: Marilyn Slavin Blumenstein, MSN, RN, 34th and Civic
© 2007 by Association of Pediatric Hematology/Oncology Nurses Center Boulevard, Hematology, Philadelphia, PA 19101; e-mail:
DOI: 10.1177/1043454207308896 Blumenstein@email.chop.edu.

Journal of Pediatric Oncology Nursing, Vol 24, No 6 (November-December), 2007; pp 309-313 309
Blumenstein

Table 1. List of Treatment Options for DVT

Observation with serial imaging and without anticoagulation
Thrombolysis with or without balloon angioplasty or Angiojet
Inferior vena cava filter placement (temporary or permanent) with or without anticoagulation
Anticoagulation
Unfractionated heparin
Low molecular weight heparin (eg, enoxaparin/Lovenox®)
Vitamin K antagonist (eg, warfarin/Coumadin®)
Direct thrombin inhibitors (eg, hirudin, argatroban)
Gradient compression therapy

Table 2. Inherited/Congenital Risks for Thrombosis Organized Using Virchow’s Triad

Alterations in Flow Vascular Endothelial Injury Hypercoagulability

May-Thurner syndrome Hyperhomocysteinemia (?) Factor V Leiden mutation

Thoracic outlet syndrome Prothrombin gene mutation
Antithrombin deficiency
Protein C deficiency
Protein S deficiency
Elevated lipoprotein (a)
Hyperhomocysteinemia
Dysfibrinogenemia

Case 1 difference in leg size recently and attributed it to his

new skill of standing and cruising while holding onto
Joann is a 16-year-old female who has a body mass furniture. Dillan’s medical history included an umbil-
index in the 90th percentile, is using estrogen- ical cord line placed during his neonatal intensive
containing oral contraception pills, and has just returned care unit stay. Anticoagulation with enoxaparin was
to the United States from a school-sponsored trip to started. Results of Dillan’s thrombophilia workup
Australia. She presented to the emergency department were normal except for factor V Leiden. He is het-
with a red, hot, swollen, and painful left leg. Doppler erozygous for the mutation. Dillan wants to crawl and
ultrasound demonstrated an occlusive DVT in her left cruise! Is it safe?
superficial femoral and external iliac veins; the infe- To help you answer this safety question, the fol-
rior vena cava was open. Oral contraception pills lowing sections provide a definition for DVT, a list of
were stopped and anticoagulation with enoxaparin treatment options (Table 1), a list of risk factors asso-
was initiated. Joann wants to get out of bed and walk ciated with the development of DVTs (Tables 2 and
around. Is it safe? 3), an introduction to postthrombotic syndrome
(PTS), and results of a literature review focused on
finding practice recommendations regarding early
Case 2 ambulation after acute DVT.

Dillan, an 11-month-old infant born at 30 weeks

gestation, was noted to have significant swelling Deep Vein Thrombosis
in his right leg at his wellness check by his primary
care provider. Imaging studies revealed an occlusive A DVT is a blood clot in any vessel of the body’s
thrombosis of his infrarenal inferior vena cava and deep venous system. DVTs can be partially or com-
right iliac vein. His parents reported noticing a slight pletely occlusive, can be fixed or embolic, and can

310 Journal of Pediatric Oncology Nursing 24(6); 2007

 Early Ambulation After Deep Vein Thrombosis

Table 3. Common Acquired Risks for Thrombosis Organized Using Virchow’s Triad

Alterations in Flow Vascular Endothelial Injury Hypercoagulability

Central lines Central lines L-asparaginase

Immobilization Increasing age Heparin-induced thrombocytopenia
Trauma Systemic lupus Estrogen/pregnancy
Surgery/anesthesia Crohn’s disease Antiphospholipid antibodies
Cancer Ulcerative colitis Renal disease
Dehydration Diabetes mellitus Cancer
Cardiac disease Infection
Prosthetic valves Trauma
Thrombocytosis Surgery
Polycythemia vera Cancer
Obesity
Smoking

develop suddenly or gradually. Patients with DVTs The third part of Virchow’s triad consists of alter-
often have inherited/congenital and/or acquired risk ations in the constitution of the blood, causing hyper-
factors that contribute to their development. More coagulability. Several congenital abnormalities in
than 140 years ago, Rudolf Virchow described throm- hemostasis have been identified, and strategies for
bosis as the result of alterations in blood flow, vascu- prevention and treatment of DVT in both adults and
lar endothelial injury, or alterations in the constitution children vary. Andrew et al. (2000) reported that
of the blood (hypercoagulability) (Ennis, 2005). without an additional acquired risk for thrombosis, it
When blood flow is sluggish in any of the body’s is rare for a child who inherits a single gene defect for
vessels for many hours, as happens when patients are thrombophilia to develop a DVT. However, children
confined to bed rest or are under general anesthesia who are homozygous for a defect or are double het-
for long operating room procedures, the first part of erozygous often present with symptoms of DVT in
this triad, alterations in blood flow, occurs. Stasis the newborn period or as children (Andrew et al.,
allows blood coagulation to be completed at the ini- 2000). Tables 2 and 3, organized using Virchow’s
tial site of thrombus formation (Hoffbrand, Moss, & triad, list the more common inherited/congenital and
Pettit, 2006). When intravascular clotting starts, it acquired risks for thrombosis, respectively.
often grows, mainly in the direction of the slowly
moving venous blood. Untreated, about 1 clot in 10
(in adults) breaks loose and travels through the right Literature Review
side of the heart into pulmonary arteries, causing a
pulmonary embolism (PE) (Guyton & Hall, 2006). Fear of causing serious or fatal PE and a belief that
The practice of prescribing bed rest after acute DVT pain and swelling would be improved faster by
stems from fear that patients will develop PEs. immobilization drive the traditional recommendation
In pediatrics, the second component in Virchow’s of bed rest in combination with anticoagulation
triad, endothelial damage, is most often incurred when (Partsch, 2005). In 1944, William Dock, writing in
a central venous catheter is placed. These lines are the Journal of the American Medical Association,
thrombogenic because they damage vessel walls and warned physicians about the hazards of complete bed
disrupt blood flow. Although central lines are essential rest. His article, “The Evil Sequelae of Complete Bed
for the medical management of pediatric patients, they Rest,” alerts readers to the dangers of this “highly
are associated with significant morbidity (>90% of unphysiologic and definitely hazardous form of ther-
DVTs in neonates and 60% of DVTs in children are apy” (p. 1084). Fear of dislodging thrombi, especially
associated with central lines) and, occasionally, mor- in the lower extremities, has prompted many physicians
tality (Andrew, Monagle, & Brooker, 2000). to disregard Dock’s advice, ignore their knowledge

Journal of Pediatric Oncology Nursing 24(6); 2007 311

Blumenstein

that immobility promotes stasis, and order lengthy collateral vein formation, and skin abnormalities that
bed rest for patients with acute DVTs. This practice is range from hyperpigmentation and induration to sta-
without evidence-based studies demonstrating that sis ulcers (Manco-Johnson, 2006). Citing 4 studies in
bed rest with anticoagulation is superior in reducing her article “How I Treat Venous Thrombosis in
the risk of PE for patients. “Bed rest has obviously Children,” Dr Manco-Johnson reported a PTS occur-
more risks concerning thrombus propagation and life- rence rate in children of 10% to 60% following DVT
threatening complications, especially in old patients, (2006). The pathophysiology of PTS begins with
and does not prevent pulmonary embolism” (Partsch, venous hypertension caused by blood flow obstruc-
2001, p. 202). tion (by the thrombus) and/or refluxed blood flow
Buller and colleagues (2004), reporting at the 7th attributable to incompetent venous valves damaged
American College of Chest Physicians Conference, by the clot or mechanical therapies directed at breaking
strongly recommended that patients with DVTs up the clot (eg, Angiojet system, Possis, Minneapolis,
ambulate as soon as possible and as much as toler- MN) (Manco-Johnson, 2006). Therapies that reduce
ated. A prospective, observational study of 2650 the incidence and severity of PTS, such as anticoagu-
patients with acute, symptomatic DVTs or pulmonary lation with early ambulation and gradient compression
embolism, all of whom were treated with low molec- therapy, have important implications for long-term
ular weight heparin, was reported (Trujillo-Santos morbidity, especially for children with DVT because
et al., 2005). Bed rest was prescribed for 54% of the they might expect to have 5 to 8 decades of life after
patients, whereas the others had early ambulation. DVT (unlike most adults with DVT).
Patients in the bed rest group tended to be sicker at The literature review can be summarized as fol-
baseline than the ambulation group, which is a limi- lows: study populations were adults, often elderly,
tation of this study. Over a 15-day period, 9 patients with no infants or children studied. All studies rec-
treated with bed rest and 6 of those ambulating devel- ommended the initiation of anticoagulation before
oped clinically evident and radiographically con- ambulation or physical therapy. Some studies recom-
firmed PEs. The authors concluded that there was no mended immediate ambulation as tolerated, whereas
apparent association between early ambulation and others suggested a 48- to 72-hour waiting period
new, symptomatic PEs (Trujillo-Santos et al., 2005). before ambulating regularly. Most studies involved
Partsch (2001) reported on 1289 consecutive DVT of the lower extremities and also recommended
patients admitted for acute DVT, all treated with low gradient compression therapy with ambulation
molecular weight heparin, early ambulation, and gra- (Aschwanden, Labs, & Engel, 2001; Ciccone, 2002;
dient compression therapy. The study, which identi- Partsch, 2000; Schellong et al., 1999). All studies
fied 5 endpoints, concluded that the low incidence of reviewed for this article concluded that early ambula-
recurrent and fatal PE in this series affirms the value tion with anticoagulation does not increase risk for
of early ambulation with leg compression therapy. patients for pulmonary embolism. Most studies
Reporting on the findings of several adult studies, reported improved outcomes on pain, swelling, and
Partsch (2001) concluded that bed rest is potentially incidence of PTS with early ambulation.
harmful. Starting therapeutic doses of anticoagulation
and encouraging patients to walk as soon and as
much as possible with good compression therapy for Conclusions and Implications
lower extremity DVT are associated with better out- for Nursing Practice
comes (decreased pain, decreased swelling, and
decreased occurrence/severity of postthrombotic Early ambulation and physical therapy are of par-
syndrome) (Partsch, 2001). ticular importance to pediatric patients at risk for loss
Although postthrombotic syndrome (PTS) is not a of range of motion, skin breakdown, or joint contrac-
focus of this article, I want to provide some informa- ture if physical therapy or ambulation orders are held
tion about it because several studies cited in this arti- as a consequence of the development of a DVT. There
cle identified a reduction in PTS incidence and/or are no published studies evaluating the safety and
severity as an important study outcome or end point. benefits of early ambulation and physical therapy in
The clinical features of PTS are pain, swelling, visible pediatric patients with acute DVTs. Clearly, this is an

312 Journal of Pediatric Oncology Nursing 24(6); 2007

 Early Ambulation After Deep Vein Thrombosis

issue nurses should study in children. In the interim, Chest Physicians’ Conference on antithrombotic and throm-
pediatric nurses and other health care providers are bolytic therapy. Chest, 126(Suppl.), 4015-4285.
Ciccone, C. D. (2002). Does ambulation immediately following
encouraged to consider the findings from the adult lit-
an episode of deep vein thrombosis increase the risk of pul-
erature on this topic to matched pediatric patients. monary embolism? Physical Therapy, 82, 84-88.
Early ambulation and physical therapy, as tolerated, Dock, W. (1944). The evil sequelae of complete bed rest. Journal
should be encouraged once anticoagulation is insti- of American Medical Association, 125, 1083-1085.
tuted. In addition, there were no reports that physical Ennis, R. S. (2005). Deep venous thrombosis prophylaxis in
therapy, such as active or passive range of motion orthopedic surgery. Retrieved September 15, 2007, from:
http://www.emedicine.com/orthoped/topic600.htm.
exercises, performed with the unaffected limbs caused Guyton, A. C., & Hall, J. E. (2006). Textbook of medical physiol-
any morbidity or mortality in patients with acute ogy. Philadelphia: Elsevier Saunders.
DVT on anticoagulation therapy. Furthermore, the Hoffbrand, A. V., Moss, P. A. H., & Pettit, J. E. (Eds.). (2006).
addition of gradient compression therapy for patients Essential haematology. Malden, MA: Blackwell.
with lower extremity DVTs seems to further improve Manco-Johnson, M. (2006). How I treat venous thrombosis in
children. Blood, 107, 21-29.
patient outcomes (Partsch, 2001). Early ambulation is
Partsch, H. (2000). Compression and walking versus bed rest in
not associated with an increased risk for pulmonary the treatment of proximal deep venous thrombosis with low
embolism in anticoagulated patients with acute deep molecular weight heparin. Journal of Vascular Surgery, 32,
vein thromboses. 861-869.
Partsch, H. (2001). Therapy of deep vein thrombosis with low
molecular weight heparin, leg compression and immediate
ambulation. Journal of Vascular Diseases, 30, 195-204.
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