Bed rest versus early ambulation with standard anticoagulation in the management of deep vein thrombosis: a meta-analysis

Abstract

Introduction: Bed rest has been considered as the cornerstone of management of deep vein thrombosis (DVT) for a long time, though it is not evidence-base, and there is growing evidence favoring early ambulation.

Methods: Electronic databases including Medline, PubMed, Cochrane Library and three Chinese databases were searched with key words of "deep vein thrombosis", "pulmonary embolism", "venous thrombosis", "bed rest", "immobilization", "mobilization" and "ambulation". We considered randomized controlled trials, prospective or retrospective cohort studies that compared the outcomes of acute DVT patients managed with early ambulation versus bed rest, in addition to standard anticoagulation. Meta-analysis pertaining to the incidence of new pulmonary embolism (PE), progression of DVT, and DVT related deaths were conducted, as well as the extent of remission of pain and edema.

Results: 13 studies were included with a total of 3269 patients. Compared to bed rest, early ambulation was not associated with a higher incidence of new PE, progression of DVT, or DVT related deaths (RD -0.03, 95% CI -0.05∼ -0.02; Z = 1.24, p = 0.22; random effect model, Tau2 = 0.01). Moreover, if the patients suffered moderate or severe pain initially, early ambulation was related to a better outcome, with respect to remission of acute pain in the affected limb (SMD 0.42, 95%CI 0.09∼0.74; Z = 2.52, p = 0.01; random effect model, Tau2 = 0.04). Meta-analysis of alleviation of edema cannot elicit a solid conclusion because of significant heterogeneity among the few studies.

Conclusions: Compared to bed rest, early ambulation of acute DVT patients with anticoagulation was not associated with a higher incidence of new PE, progression of DVT, and DVT related deaths. Furthermore, for the patients suffered moderate or severe pain initially, a better outcome can be seen in early ambulation group, regarding to the remission of acute pain in the affected limb.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1. Flow diagram of study selection.

Fig 2. Summary of risk of bias for RCTs (RevMan 5.3).

Red: High risk; Yellow: Unclear risk; Green: Low risk * Because the studies compared bed rest versus ambulation, it is too easy for the patients to find out which group they are in. So it is not likely to fulfill the requirement of blinding of participants. ** Details about the reasons for this assessment are listed in the supporting information S3 Table.

Fig 3. Funnel plot of studies included.

Fig 4. Begg’s and Egger’s tests for publication bias of included studies.

Fig 5. Meta-analysis of the incidence of primary end events among 1674 DVT patients with early ambulation and 1595 DVT patients with bed rest.

Fig 6. Meta-analysis of VAS change.

In this figure, the data in “Mean” and “SD” column is the mean change of VAS rather than initial mean VAS.

Fig 7. Subgroup analysis of VAS change during the treatment period.

Fig 8. Meta-analysis of change of circumference of affected limb.