A 74-year-old man recovering from recent ischemic stroke develops right ankle and calf swelling. He has mild, persistent right-sided hemiplegia and has been receiving daily physical therapy for the last week. Compression ultrasonography confirms right-sided popliteal vein thrombosis. The patient is started on a therapeutic dose of enoxaparin twice daily.
When is it appropriate for this patient to resume mobilization and physical therapy?

Question

A 74-year-old man recovering from recent ischemic stroke develops right ankle and calf swelling.  He has mild, persistent right-sided hemiplegia and has been receiving daily physical therapy for the last week.  Compression ultrasonography confirms right-sided popliteal vein thrombosis.  The patient is started on a therapeutic dose of enoxaparin twice daily.
When is it appropriate for this patient to resume mobilization and physical therapy?

Quizplus · Accepted Answer

Bed rest following deep venous thrombosis (DVT) was advised in the past due to concern for embolization to the lungs upon mobilization. But several studies have shown that early ambulation does not increase the risk of pulmonary embolism (PE). Compared to prolonged bed rest, early ambulation is associated with more rapid improvement in pain, as well as a lower risk of: DVT extensionPEMortalityPost-thrombotic syndrome DVT extension PE Mortality Post-thrombotic syndrome The optimal time for resuming ambulation is unclear, but mobilization is likely appropriate as soon as therapeutic levels of anticoagulation are reached (eg, within 24 hours of starting enoxaparin). (Choice A) Therapeutic levels of anticoagulation are reached within 24 hours of enoxaparin initiation; 3-5 days are usually needed to achieve therapeutic levels of anticoagulation when warfarin is initiated (eg, goal INR 2-3), although patients are often simultaneously bridged with a heparin compound. (Choice B) Inferior vena cava filters are indicated when a patient cannot receive anticoagulation. They are not needed before mobilization. (Choice C) There is no evidence that oral anticoagulation is needed before reinitiation of ambulation. (Choice D) Repeat lower extremity ultrasound is not needed prior to ambulation. Clots that do not fully resolve are not a risk for embolization, though they are associated with a higher risk of post-thrombotic syndrome. Educational objective: Early ambulation following deep venous thrombosis is associated with fewer complications compared to prolonged bed rest. It is reasonable to start mobilization once therapeutic levels of anticoagulation have been reached. __________ References: Ambulation after deep vein thrombosis: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/20514175) Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/22315268) A meta-analysis of bed rest versus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both. (http://www.ncbi.nlm.nih.gov/pubmed/18691773)

A 74-Year-Old Man Recovering from Recent Ischemic Stroke Develops Right