Early Ambulation After Acute Deep Vein
Thrombosis: Is It Safe?
Marilyn Slavin Blumenstein, MSN, RN
The number of thrombotic events in children,
although significantly less than that in adults, is
increasing as a result of therapeutic advances in pri-
mary illnesses that were previously fatal. When a
patient, adult or pediatric, develops a deep vein
thrombosis and anticoagulation therapy is initiated,
many health professionals ask, “When should this
patient have physical therapy and/or ambulate?”
Fear of causing a pulmonary embolism with
increased activity drives this question. Often, an
order for bed rest is prescribed based more on tradi-
tion than on evidence-based medicine. A review of the
literature has provided an evidence-based answer to
the question, and although the studies are all of adult
populations, the results have been extrapolated for
use with comparable pediatric populations. The
majority of studies agree that early ambulation does
not increase an anticoagulated patient’s risk for pul-
monary embolism. Moreover, most studies report that
early ambulation carries benefits such as decreased
pain and swelling and fewer postthrombotic syn-
drome symptoms.
Key words: deep vein thrombosis, ambulation, physi-
cal therapy, pulmonary embolism, children
R ecently, a pediatric physical therapy manager
asked me for practice recommendations for her
staff when they are working with children with deep
© 2007 by Association of Pediatric Hematology/Oncology Nurses
DOI: 10.1177/1043454207308896
Journal of Pediatric Oncology Nursing, Vol 24, No 6 (November-December), 2007; pp 309-313
vein thrombosis (DVT). Her staff had 4 questions:
(1) Is it correct to hold ambulation/out-of-bed orders
if there is a suspected DVT or if an ultrasound result
is pending? (2) Once a DVT is diagnosed and the
patient is placed on anticoagulant therapy using
enoxaparin (Lovenox®), how long until the patient is
out of bed and/or ambulating? (3) With DVTs, are
bed exercises on the unaffected limbs allowed? (4)
Who is the point person for questions related to
ambulation and physical therapy for patients with
DVTs? Questions like these are also asked by other
health care providers who are responsible for the day-
to-day supervision and coordination of patient activi-
ties. One-size-fits-all answers to these questions are
unhelpful and potentially dangerous. The attending
physician responsible for the patient, sometimes in
collaboration with a hematologist, is in the best posi-
tion to direct the patient’s care. Our pediatric physical
therapy manager was advised to continue to collabo-
rate with the patient’s attending physician. In addi-
tion, I conducted a literature search and evaluated the
evidence-based clinical research concerning ambula-
tion in the setting of acute DVT. Those results were
used to inform our practice and are offered here so
that other pediatric nursing and physical therapy
groups can inform their practices too.
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
Center Boulevard, Hematology, Philadelphia, PA 19101; e-mail:
Blumenstein@email.chop.edu.
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
May-Thurner syndrome Hyperhomocysteinemia (?)
Thoracic outlet syndrome
Case 1
Joann is a 16-year-old female who has a body mass
index in the 90th percentile, is using estrogen-
containing oral contraception pills, and has just returned
to the United States from a school-sponsored trip to
Australia. She presented to the emergency department
with a red, hot, swollen, and painful left leg. Doppler
ultrasound demonstrated an occlusive DVT in her left
superficial femoral and external iliac veins; the infe-
rior vena cava was open. Oral contraception pills
were stopped and anticoagulation with enoxaparin
was initiated. Joann wants to get out of bed and walk
around. Is it safe?
Case 2
Dillan, an 11-month-old infant born at 30 weeks
gestation, was noted to have significant swelling
in his right leg at his wellness check by his primary
care provider. Imaging studies revealed an occlusive
thrombosis of his infrarenal inferior vena cava and
right iliac vein. His parents reported noticing a slight
310
Hypercoagulability
Factor V Leiden mutation
Prothrombin gene mutation
Antithrombin deficiency
Protein C deficiency
Protein S deficiency
Elevated lipoprotein (a)
Hyperhomocysteinemia
Dysfibrinogenemia
difference in leg size recently and attributed it to his
new skill of standing and cruising while holding onto
furniture. Dillan’s medical history included an umbil-
ical cord line placed during his neonatal intensive
care unit stay. Anticoagulation with enoxaparin was
started. Results of Dillan’s thrombophilia workup
were normal except for factor V Leiden. He is het-
erozygous for the mutation. Dillan wants to crawl and
cruise! Is it safe?
To help you answer this safety question, the fol-
lowing sections provide a definition for DVT, a list of
treatment options (Table 1), a list of risk factors asso-
ciated with the development of DVTs (Tables 2 and
3), an introduction to postthrombotic syndrome
(PTS), and results of a literature review focused on
finding practice recommendations regarding early
ambulation after acute DVT.
Deep Vein Thrombosis
A DVT is a blood clot in any vessel of the body’s
deep venous system. DVTs can be partially or com-
pletely occlusive, can be fixed or embolic, and can
Journal of Pediatric Oncology Nursing 24(6); 2007

Table 3. Common Acquired Risks for Thrombosis Organized Using Virchow’s Triad
Alterations in Flow Vascular Endothelial Injury
Central lines
Immobilization
Trauma
Surgery/anesthesia
Cancer
Dehydration
Cardiac disease
Prosthetic valves
Thrombocytosis
Polycythemia vera
develop suddenly or gradually. Patients with DVTs
often have inherited/congenital and/or acquired risk
factors that contribute to their development. More
than 140 years ago, Rudolf Virchow described throm-
bosis as the result of alterations in blood flow, vascu-
lar endothelial injury, or alterations in the constitution
of the blood (hypercoagulability) (Ennis, 2005).
When blood flow is sluggish in any of the body’s
vessels for many hours, as happens when patients are
confined to bed rest or are under general anesthesia
for long operating room procedures, the first part of
this triad, alterations in blood flow, occurs. Stasis
allows blood coagulation to be completed at the ini-
tial site of thrombus formation (Hoffbrand, Moss, &
Pettit, 2006). When intravascular clotting starts, it
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
side of the heart into pulmonary arteries, causing a
pulmonary embolism (PE) (Guyton & Hall, 2006).
The practice of prescribing bed rest after acute DVT
stems from fear that patients will develop PEs.
In pediatrics, the second component in Virchow’s
triad, endothelial damage, is most often incurred when
a central venous catheter is placed. These lines are
thrombogenic because they damage vessel walls and
disrupt blood flow. Although central lines are essential
for the medical management of pediatric patients, they
are associated with significant morbidity (>90% of
DVTs in neonates and 60% of DVTs in children are
associated with central lines) and, occasionally, mor-
tality (Andrew, Monagle, & Brooker, 2000).
Journal of Pediatric Oncology Nursing 24(6); 2007
Early Ambulation After Deep Vein Thrombosis
Hypercoagulability
Central lines L-asparaginase
Increasing age Heparin-induced thrombocytopenia
Systemic lupus Estrogen/pregnancy
Crohn’s disease Antiphospholipid antibodies
Ulcerative colitis Renal disease
Diabetes mellitus Cancer
Infection
Trauma
Surgery
Cancer
Obesity
Smoking
The third part of Virchow’s triad consists of alter-
ations in the constitution of the blood, causing hyper-
coagulability. Several congenital abnormalities in
hemostasis have been identified, and strategies for
prevention and treatment of DVT in both adults and
children vary. Andrew et al. (2000) reported that
without an additional acquired risk for thrombosis, it
is rare for a child who inherits a single gene defect for
thrombophilia to develop a DVT. However, children
who are homozygous for a defect or are double het-
erozygous often present with symptoms of DVT in
the newborn period or as children (Andrew et al.,
2000). Tables 2 and 3, organized using Virchow’s
triad, list the more common inherited/congenital and
acquired risks for thrombosis, respectively.
Literature Review
Fear of causing serious or fatal PE and a belief that
pain and swelling would be improved faster by
immobilization drive the traditional recommendation
of bed rest in combination with anticoagulation
(Partsch, 2005). In 1944, William Dock, writing in
the Journal of the American Medical Association,
warned physicians about the hazards of complete bed
rest. His article, “The Evil Sequelae of Complete Bed
Rest,” alerts readers to the dangers of this “highly
unphysiologic and definitely hazardous form of ther-
apy” (p. 1084). Fear of dislodging thrombi, especially
in the lower extremities, has prompted many physicians
to disregard Dock’s advice, ignore their knowledge
311
Blumenstein
that immobility promotes stasis, and order lengthy
bed rest for patients with acute DVTs. This practice is
without evidence-based studies demonstrating that
bed rest with anticoagulation is superior in reducing
the risk of PE for patients. “Bed rest has obviously
more risks concerning thrombus propagation and life-
threatening complications, especially in old patients,
and does not prevent pulmonary embolism” (Partsch,
2001, p. 202).
Buller and colleagues (2004), reporting at the 7th
American College of Chest Physicians Conference,
strongly recommended that patients with DVTs
ambulate as soon as possible and as much as toler-
ated. A prospective, observational study of 2650
patients with acute, symptomatic DVTs or pulmonary
embolism, all of whom were treated with low molec-
ular weight heparin, was reported (Trujillo-Santos
et al., 2005). Bed rest was prescribed for 54% of the
patients, whereas the others had early ambulation.
Patients in the bed rest group tended to be sicker at
baseline than the ambulation group, which is a limi-
tation of this study. Over a 15-day period, 9 patients
treated with bed rest and 6 of those ambulating devel-
oped clinically evident and radiographically con-
firmed PEs. The authors concluded that there was no
apparent association between early ambulation and
new, symptomatic PEs (Trujillo-Santos et al., 2005).
Partsch (2001) reported on 1289 consecutive
patients admitted for acute DVT, all treated with low
molecular weight heparin, early ambulation, and gra-
dient compression therapy. The study, which identi-
fied 5 endpoints, concluded that the low incidence of
recurrent and fatal PE in this series affirms the value
of early ambulation with leg compression therapy.
Reporting on the findings of several adult studies,
Partsch (2001) concluded that bed rest is potentially
harmful. Starting therapeutic doses of anticoagulation
and encouraging patients to walk as soon and as
much as possible with good compression therapy for
lower extremity DVT are associated with better out-
comes (decreased pain, decreased swelling, and
decreased occurrence/severity of postthrombotic
syndrome) (Partsch, 2001).
Although postthrombotic syndrome (PTS) is not a
focus of this article, I want to provide some informa-
tion about it because several studies cited in this arti-
cle identified a reduction in PTS incidence and/or
severity as an important study outcome or end point.
The clinical features of PTS are pain, swelling, visible
312
collateral vein formation, and skin abnormalities that
range from hyperpigmentation and induration to sta-
sis ulcers (Manco-Johnson, 2006). Citing 4 studies in
her article “How I Treat Venous Thrombosis in
Children,” Dr Manco-Johnson reported a PTS occur-
rence rate in children of 10% to 60% following DVT
(2006). The pathophysiology of PTS begins with
venous hypertension caused by blood flow obstruc-
tion (by the thrombus) and/or refluxed blood flow
attributable to incompetent venous valves damaged
by the clot or mechanical therapies directed at breaking
up the clot (eg, Angiojet system, Possis, Minneapolis,
MN) (Manco-Johnson, 2006). Therapies that reduce
the incidence and severity of PTS, such as anticoagu-
lation with early ambulation and gradient compression
therapy, have important implications for long-term
morbidity, especially for children with DVT because
they might expect to have 5 to 8 decades of life after
DVT (unlike most adults with DVT).
The literature review can be summarized as fol-
lows: study populations were adults, often elderly,
with no infants or children studied. All studies rec-
ommended the initiation of anticoagulation before
ambulation or physical therapy. Some studies recom-
mended immediate ambulation as tolerated, whereas
others suggested a 48- to 72-hour waiting period
before ambulating regularly. Most studies involved
DVT of the lower extremities and also recommended
gradient compression therapy with ambulation
(Aschwanden, Labs, & Engel, 2001; Ciccone, 2002;
Partsch, 2000; Schellong et al., 1999). All studies
reviewed for this article concluded that early ambula-
tion with anticoagulation does not increase risk for
patients for pulmonary embolism. Most studies
reported improved outcomes on pain, swelling, and
incidence of PTS with early ambulation.
Conclusions and Implications
for Nursing Practice
Early ambulation and physical therapy are of par-
ticular importance to pediatric patients at risk for loss
of range of motion, skin breakdown, or joint contrac-
ture if physical therapy or ambulation orders are held
as a consequence of the development of a DVT. There
are no published studies evaluating the safety and
benefits of early ambulation and physical therapy in
pediatric patients with acute DVTs. Clearly, this is an
Journal of Pediatric Oncology Nursing 24(6); 2007
 Early Ambulation After Deep Vein Thrombosis

issue nurses should study in children. In the interim,
pediatric nurses and other health care providers are
encouraged to consider the findings from the adult lit-
erature on this topic to matched pediatric patients.
Early ambulation and physical therapy, as tolerated,
should be encouraged once anticoagulation is insti-
tuted. In addition, there were no reports that physical
therapy, such as active or passive range of motion
exercises, performed with the unaffected limbs caused
any morbidity or mortality in patients with acute
DVT on anticoagulation therapy. Furthermore, the
addition of gradient compression therapy for patients
with lower extremity DVTs seems to further improve
patient outcomes (Partsch, 2001). Early ambulation is
not associated with an increased risk for pulmonary
embolism in anticoagulated patients with acute deep
vein thromboses.
References
Andrew, M., Monagle, P. T., & Brooker, L. (2000).
Thromboembolic complications during infancy and child-
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Aschwanden, M., Labs, K. H., & Engel, H. (2001). Acute deep
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