Article Figures & Tables
Figures
- Figure 1:
Selection process for studies describing ambulation as a therapy for preventing venous thromboembolism in patients admitted to hospitals. Note: ICU = intensive care unit, VTE = venous thromboembolism.
Tables
- Table 1:
Characteristics of included studies of ambulation to prevent venous thromboembolism
Study Year Country Study design Patient population Groups n Male no. (%) Age, yr; mean ± SD Miller et al (39) 1976 US RCT Medicine (acute MI and heart failure) Early ambulation 21 NR NR Bed rest 8 NR NR Prerovský et al (40) 1988 Amsterdam RCT Medicine (acute MI) Active foot flexion 135 109 (81) 59 ± 9 Heparin 133 101 (76) 58 ± 9 Control 140 109 (78) 59 ± 8 Vioreanu et al (41) 2007 Ireland RCT Orthopedics (foot and ankle) Cast immobilization 29 20 (69) 35 ± 16 Early ambulation 33 21 (64) 37 ± 13 Sorbello et al (42) 2009 Australia RCT Medicine (stroke) Standard of care 33 16 (48) 75 ± 10 Early mobilization 38 22 (58) 75 ± 15 Amin et al (46) 2010 France Secondary analysis of RCT Medicine Ambulatory 607 317 (52) 72 ± 11 Nonambulatory 447 226 (47) 75 ± 10 Wang et al (43) 2016 China RCT Orthopedics Control 78 65 (83) 54 ± 6 Active ankle movements 96 78 (81) 52 ± 7 de Almeida et al (44) 2017 Italy RCT General surgery Control 54 22 (41) 62 (51–68)* Early mobilization 54 21 (39) 61 (53–70)* Guo et al (45) 2019 China RCT Gynecology (surgical oncology) Control 53 0 (0) 52 ± 13 Functional exercises 62 0 (0) 48 ± 11 Lassen and Borris (29) 1991 Denmark Prospective cohort Orthopedics (THA) POD #4 mobilization (Gr1) 35 NR NR POD #9 mobilization (Gr2) 16 NR NR Gr2 mobilization to POD #4 19 NR NR Karic et al (30) 2017 Norway Prospective cohort Neurosurgery (aneurysmal repair) Control 77 28 (36) 54 (25–79)* Early mobilization 94 28 (30) 57 (25–81)* Moses (32) 1951 US Retrospective cohort Surgery Control 74 NR NR Bicycle exercise 74 NR NR Flanc et al (33) 1969 England Retrospective cohort Surgery Control 65 NR NR Supervised exercise 67 NR NR Pearse et al (34) 2007 US Retrospective cohort Orthopedics (TKA) Early mobilization 97 54 (56) 69 (SD NR) Control 98 48 (49) 69 (SD NR) Chandrasekaran et al (35) 2009 Australia Retrospective cohort Orthopedics (TKA) Before ambulation protocol 50 21 (42) 73 (SD NR) After ambulation protocol 50 24 (48) 71 (SD NR) Frantzides et al (36) 2012 US Retrospective cohort General surgery (bypass) Ambulation protocol 1257 NR NR Heparin protocol 435 NR NR Cassidy et al (37) 2014 US Retrospective cohort (NSQIP) Surgery Before VTE protocol 1569 NR NR After VTE QI protocol 1323 NR NR Bhatt et al (31) 2017 Ireland Retrospective cohort General surgery Control 30 18 (60) 61 ± 15 Exercise program 30 17 (57) 61 ± 14 Silver et al (38) 2020 US Retrospective cohort Medical (ischemic stroke) Control (24 h bed rest) 203 97 (52) 72 ± 16 12 h bed rest 189 87 (46) 72 ± 16 Note: Gr = Grade of mobilization, MI = myocardial infarction, NR = not reported, NSQIP = National Surgical Quality Improvement Program, POD = postoperative day, QI = quality improvement, RCT = randomized controlled trial, SD = standard deviation, THA = total hip arthroplasty, TKA = total knee arthroplasty, VTE = venous thromboembolism.
↵* Median (interquartile range).
Study Ambulatory group description Ambulation quantified? Comparison group description Pharmacological VTE prophylaxis Outcome (definition) Group sizes Results Study conclusion Miller et al (39) Sitting and standing at the bedside for 30 min 3 times/d; ate meals while sitting No Five days of bed rest with leg exercises hourly No DVT (125I-fibrinogen) 21 Amb 10% Early mobilization program reduces the incidence of venous thrombosis in acute MI 8 Control 63% Prerovský et al (40) Dorsal and plantar flexion for 1–2 min every hour while awake No Standard of care without chemical VTE prophylaxis No* DVT (125I-fibrinogen) 135 Amb 5.2% Moderate lower limb exercise is the simplest measure to prevent VTE 133 Heparin 9.0% 140 Control 13.6% Vioreanu et al (41) Custom made removable fiberglass cast with ankle exercises 3 times/d for 10 min No Non-removable fiberglass cast for 6 weeks NR VTE 29 Amb 0% Postoperative immobilization may increase DVT risk Clinical 33 Control 6% Sorbello et al (42) Sitting or standing within 24 h for 6 d with aid of nurse or physiotherapist No Standard of care NR VTE (NR) 33 Amb 0% No difference in complications after initiation of early mobilization 38 Control 0% Amin et al (46) Ability to attain autonomous walking distance > 10 m Yes Did not attain autonomous walking > 10 m Yes† VTE (clinical) 607 Amb 8.4%‡ In the prevention of VTE, reaching ambulatory status may not be a reason for stopping pharmacological prophylaxis 447 Control 16.2% Wang et al (43) Dorsal and plantar flexion 30 times/min, 20 times/d in first 7 postoperative days No Standard of care NR DVT (doppler or clinical) 78 Amb 7.6% Significant reduction in all DVTs but no difference in symptomatic DVTs (2.2% v. 3.9%) 96 Control 18.4% de Almeida et al (44) Twice daily exercise program based on patient’s functional ability Yes Once daily exercise program NR DVT (clinical) 54 Amb 1.8% Primary outcome was ability to walk but no difference in DVT 54 Control 0% Guo et al (45) Active ankle motions, calf massage and deep breathing No Standard of care Yes DVT (clinical or ultrasonography) 53 Amb 1.9% Because of the sample size limitation, the authors could not draw any conclusion about the effects of exercise on the prevention of VTE 62 Control 1.6% Lassen and Borris (29) Mobilized from postoperative day 4 onward No Mobilized from postoperative day 9 onward Yes DVT (phlebography) 35 Amb 21% Patients may lose benefit of pharmacological VTE prophylaxis if they are not mobilized 35 Control 75% Karic et al (30) Progressive mobilization from HOB elevation to sitting, standing and walking to restroom No Standard of care Yes VTE (clinical) 77 Amb 4.2% No impact on VTE but reduced postoperative vasospasm 94 Control 3.8% Moses (32) Forced respirations and 2-min bicycle exercise every day or twice daily while awake No Standard of care NR VTE (clinical) 74 Amb 0% Bicycle or deep breathing reduce thrombotic complications 74 Control 5% Flanc et al (33) Supervised exercise 6 times/d with nursing reminders to exercise No Standard of care NR DVT (125I-fibrinogen) 65 Amb 25% Strain on hospital resources and only benefit was in older patients 67 Control 35% Pearse et al (34) VTE prevention protocol including < 24 h mobilization No Routine ambulation on POD #2 Yes DVT (Doppler) 97 Amb 1% Early mobilization reduces radiographic DVT 98 Control 28% Chandrasekaran et al (35) Mobilized with first 24 h, at least twice daily, 15–30 min, by physiotherapists Yes (sitting, 1–5 m, > 5 m) Routine out of bed to chair and walking POD #2 Yes VTE (Doppler or clinical) 50 Amb 16% Early mobilization reduces postoperative DVT, particularly if > 5 m (no VTE in 15 patients) 50 Control 38% Frantzides et al (36) VTE prevention protocol including ambulation within 2 h No Standard of care with enoxaparin Yes (control only) VTE (NR) 1257 Amb 0.5% Early ambulation as part of a comprehensive protocol obviates need for pharmacological prophylaxis except in high-risk patients 435 Control 2.7% Cassidy et al (37) New comprehensive VTE prevention protocol including mobilization 3 times/d No Prior to protocol with no predefined practice Yes (according to risk assessment) VTE (NSQIP) 1569 Amb 3% Postoperative mobilization program, risk stratification and electronic recommendations reduce VTE 1323 Control 0.8% Bhatt et al (31) Twice daily exercise program with pedal exerciser or POD#2 or when able to sit Yes Standard of care NR VTE (clinical) 30 Amb 0% No impact on VTE but reduced infectious complications postoperatively 30 Control 0% Silver et al (38) Bedrest for = 24 h No At least 12 h of bedrest No DVT (clinical) 203 Amb 0.5% No effect on VTE but reduction in pneumonia and LOS 189 Control 1.5% Note: Amb = ambulation, DVT = deep vein thrombosis, HOB = head of bed, LOS = length of stay, MI = myocardial infarction, NR = not reported, NSQIP = National Surgical Quality Improvement Program, POD = postoperative day, RCT = randomized controlled trial, VTE = venous thromboembolism.
↵* Ambulation and Enoxaparin 40 mg once daily had the lowest rate of VTE at 3.3%.
↵† Heparin was used in a third group but not ambulatory or control group.
↵‡ Patients in both groups were randomly assigned to receive placebo, enoxaparin 40 mg or 20 mg once daily.
- Table 3:
Quality of included studies and assessment of bias, as evaluated by Downs and Black (28)
Study Year Study design Measure Score Overall quality* Quality of reporting External validity Internal validity Power Moses (32) 1951 Retrospective cohort 2 1 1 0 4 Poor Flanc et al (33) 1969 Retrospective cohort 7 2 6 0 14 Fair Miller et al (39) 1976 RCT 5 1 6 0 12 Poor Prerovský et al (40) 1988 RCT 6 2 6 0 14 Fair Lassen and Borris (29) 1991 Prospective cohort 3 1 4 0 8 Poor Pearse et al (34) 2007 Retrospective cohort 9 0 6 0 15 Fair Vioreanu et al (41) 2007 RCT 7 3 6 0 16 Fair Chandrasekaran et al (35) 2009 Retrospective cohort 8 1 8 0 17 Fair Sorbello et al (42) 2009 RCT 10 3 7 0 20 Good Amin et al (46) 2010 Secondary analysis of RCT 11 3 9 0 23 Good Frantzides et al (36) 2012 Retrospective cohort 7 3 4 0 14 Fair Cassidy et al (37) 2014 Retrospective cohort (NSQIP) 8 3 8 0 19 Good Bhatt et al (31) 2017 Retrospective cohort 8 2 6 0 16 Fair Wang et al (43) 2016 RCT 8 1 9 0 18 Fair Karic et al (30) 2017 Prospective cohort 8 3 6 1 18 Fair de Almeida et al (44) 2017 RCT 11 3 11 1 26 Excellent Guo et al (45) 2019 RCT 11 2 11 1 25 Good Silver et al (38) 2019 Retrospective cohort 9 3 5 0 17 Fair Note: NSQIP = National Surgical Quality Improvement Program, RCT = randomized controlled trial.
↵* Scale for quality scores: poor: ≤ 14; fair: 15–19; good: 20–25; excellent: 26–28.
- Table 4:
Results of included studies rated “good” or “excellent” quality
Study Study size Study population Study quality* Ambulation quantified? Pharmacological VTE prophylaxis Outcome (definition) Results Study conclusion Notes Sorbello et al (42) 71 Medicine Good No NR VTE (NR) Amb 0% No difference in complications after initiation of early mobilization Physiotherapy-directed OR physiotherapist-directed ambulation early in admission did not change VTE rates compared with standard of care Control 0% Amin et al (46) 1054 Medicine Good Yes Yes† VTE (clinical) Amb 8.4%‡ In the prevention of VTE, reaching ambulatory status may not be a reason for stopping chemical prophylaxis The best study to quantify ambulation (> 10 m walking). Reinforces need for chemical VTE prophylaxis Control 16.2% Cassidy et al (37) 2892 Surgery Good No Yes, according to risk assessment VTE (NSQIP) Amb 3% Postoperative mobilization program, risk stratification and electronic recommendations reduce VTE Large study with definition of VTE used widely. Wide implementation of a 3 times/d regimen failed to show a reduction in VTE Control 0.8% de Almeida et al (44) 108 Surgery Excellent Yes NR DVT (clinical) Amb 1.8% Primary outcome was ability to walk but no difference in DVT VTE events were a secondary outcome. More ambulation (≥ 2 times/d compared with ≤ 1 time/d) did not reduce VTE events Control 0% Guo et al (45) 115 Surgery Good No Yes DVT (clinical or ultrasonography) Amb 1.6% Because of the sample size limitation, the authors could not draw any conclusion about the effects of exercises on the prevention of VTE Similar to other lower quality studies, ankle exercises do not seem to reduce risk of DVT Control 1.9% Note: Amb = ambulation, NR = not reported, NSQIP = National Surgical Quality Improvement Program, VTE = venous thromboembolism (pulmonary embolism or deep vein thrombosis [DVT])
↵* Assessed using the Downs and Black tool. (28)
↵† Patients in both groups were randomly assigned to receive placebo or enoxaparin 40 mg or 20 mg once daily.
↵‡ Ambulation and enoxaparin 40 mg once daily had the lowest rate of VTE at 3.3%.
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