According to the World Health Organization, mobility is the ability of a person to move from one place to another, regardless of whether they need assistance or if it is unaided. This movement is achieved by the interaction between the person’s energy and the environment and is often judged by the person’s level of physical activity. Physical activity is a broad term referring to energy expenditure…
Varicose veins are more prone to come with age due to the natural loss of elasticity in the veins. Varicose vein can cause moderate to severe pain in the legs in up to 4.8 million people in the USA. Chronic venous insufficiency affects 2% of all Americans, and brawny skin discoloration affects approximately 500,000. Each year, 500,000 people in the USA are reported to have venous leg ulcers, and it is estimated that 50% of all leg ulcers are caused by varicose veins. At this rate, it is extremely likely that the impact of varicose veins on mobility and physical activity will affect a majority of individuals in the USA and continue to be a growing problem.
Varicose veins are a common problem in the United States, affecting 50-60% of the people in the nation. It is defined as abnormally and irregularly swollen veins, most commonly affecting the legs, and is caused by venous reflux, a condition in which blood flow in the veins flows in the wrong direction. Varicose veins can cause chronic venous insufficiency, brawny skin discoloration, and in severe cases, venous leg ulcers. Although varicose veins are not life-threatening, they can cause moderate to severe pain and restrict mobility and physical function, which in turn can significantly impair one’s quality of life. This essay will review key issues concerning the impact of varicose veins on mobility and physical activity throughout different ages and how it affects the quality of life of individuals suffering from varicose veins.
Overview of varicose veins
Varicose veins are distended, twisted veins that are visible just beneath the surface of the skin. They occur when the valves in the veins do not work properly, so that the blood does not flow effectively from the legs to the heart. Veins have leaflet valves to prevent blood from flowing backwards (retrograde). Leg muscles pump the veins to return blood to the heart against the effects of gravity. When the veins become varicose, it means that they are not functioning effectively and are failing to effectively help the blood return to the heart. This can cause an aching, heavy feeling in the legs with some pain. The factors that contribute to the cause of varicose veins are pregnancy, old age and there are others such as being confined to a standing position and abdominal straining which are the result of an increase in the duration of increased pressure on the blood with gravity. This specific type of vein could lead to this research topic, due to how it can hinder the mobility and physical aspects of the person inflicted. Shown in some rare cases, varicose veins may lead to more serious health problems. An example of this is when ulceration of the legs occurs, due to chronic increase in venous pressure and white blood cells that cause blood vessels to weaken and become inflamed, damaging their inner walls and leading to the formation of ulcers.
Prevalence of varicose veins
Chronic venous disease is common in Western societies. By pooling the results from 14 centers in different countries that performed venous duplex ultrasound, the prevalence of varicose veins was thought to be between 10% and 20% of adult men and between 25% and 33% of adult women. In a Dutch study based on a telephone questionnaire, the prevalence of trunk varices, which were defined as any saphenous or non-saphenous veins of > 3mm, was 17% in men and 33% in women. When this was expanded to include all visible varicose veins, the prevalence increased to 38%. In British adults, the CREST questionnaire studies estimated that the overall prevalence of varicose veins was 44%, with 15% of men and 25% of women reporting just trunk veins and 29% of men and 38% of women reporting more severe visible varicosities. In a community-based cross-sectional study in Edinburgh, the overall prevalence of varicose veins based on the report of veins > 2mm in diameter was 32%. The San Diego population-based study found that 24.9% of the general population had CEAP 2 to CEAP 6 venous disease. These studies show that varicose veins and venous reflux have a high prevalence in the adult population.
Importance of mobility and physical activity
Varicose vein disorder is a common and important problem in the United States and other Western societies, and is a cardinal indicator of venous insufficiency. It has been estimated that as many as 60% of men and women in the United States have some form of the disorder. Women, however, are affected approximately twice as frequently as men. Symptoms and the need for medical treatment increase with age and affect 20-25% of adults aged 40-80. Venous leg symptoms are essential to evaluate in understanding the full spectrum of venous disease, and varicose veins themselves are an important reminder that the entire venous system is abnormal. It is reasonable to think of them both as a cosmetic problem and as a sign of potentially progressive venous disease. The impact of varicose veins on patients’ activities, symptoms, and well-being has not been adequately studied, but there is preliminary evidence to suggest substantial impact on quality of life. A systematic evaluation of how varicose veins and chronic venous insufficiency impact overall quality of life and work productivity is a critical need.
Effects of varicose veins on mobility
Questionnaire studies have shown that people with varicose veins have a reduced capacity for energy expenditure. Pain, ankle swelling, and leg cramps were significantly more common in subjects with reflux and/or obstruction of the deep venous system, indicating that symptoms were more severe when there was advanced venous disease. Symptoms were most severe in those with active or healed leg ulcers, but were also significant in those with skin changes. A variety of lower limb symptoms or functional abnormalities were reported on a symptom checklist by a group of patients being assessed for deep venous reflux. All symptoms were more common in those with reflux. With increasing age, the prevalence of ankle swelling, leg cramps, and night cramps has been shown to be much higher in women with varicose veins than in women without. A decrease in health-related quality of life for women increases with severity of symptoms.
A Japanese study using Health-Related Quality of Life questionnaires showed that patient-reported physical quality of life was lower for those with venous leg ulcers than for those with diabetes, hypertension, or other chronic conditions. Varicose veins are a major cause of leg ulceration, and ulcers result in the greatest reduction in mobility. In a study to assess the walking speed of elderly people in the community, those with chronic leg ulcers had the slowest walking speed. In another study assessing functional ability in older people, venous disease was associated with a greater number of physical impairments.
Mobility is the ability to move purposefully from place to place. Any factors that limit mobility have major consequences, not only for an individual’s health, but also for their independence and ability to participate in society. While the majority of people with varicose veins have no symptoms, a minority suffer enough discomfort to seek medical help.
Reduced ability to walk long distances
The second reason is that it has been shown to be a significant factor in the development of deep vein thrombosis (DVT), a potentially life-threatening condition where a thrombus (clot) forms in the deep veins of the legs. DVT often occurs after sitting in one place for a long time, such as on a long-haul flight, where lack of movement and reduced calf muscle action allows the blood to pool in the vein. If a piece of the thrombus breaks off, it can travel up through the heart and become lodged in the arteries of the lung, forming a pulmonary embolism, which can be instantly fatal. A systematic review and meta-analysis of observational studies showed that there was a strong association between varicose veins and DVT, with a pooled relative risk of 2.47, increasing to 5.34 for those with a history of VV. Although the exact mechanism through which varicose veins increase the risk of DVT is not fully understood, it is likely to be due to a combination of venous stasis and inflammation. This shows that the measure of a patient’s ability to walk long distances has implications not only for their varicose veins but also for potentially life-threatening conditions.
Reduced ability to walk long distances can be seen as the most significant effect of varicose veins on mobility for several reasons. Firstly, because it is usually the first symptom that patients notice and the main reason that they seek medical advice. Secondly, as the presence of varicose veins restricts the range of ankle movement, particularly upwards, it limits the calf muscle pump action, which is the dominant mechanism by which blood is returned from the superficial veins in the legs. When the calf muscle contracts, the vein is squeezed and blood is pushed upwards towards the heart. When the pressure is released, blood is sucked in through small one-way valves, preventing it from flowing backwards away from the heart. If these valves fail due to lack of movement or increased age, blood collects in the veins and the pressure is transmitted down, distending the veins and leading to their becoming varicose.
Difficulty climbing stairs
This means that the calf is not able to easily push the blood upwards. This will lead to an increased load of blood in the veins of the leg and also increased pressure. Blood will tend to leak out of the veins and cause staining or dermatitis of the skin in the lower leg. This, in turn, will lead to inflammation, which increases the likelihood of swelling. In addition to the increased load of blood and pressure, the increased inflammation and swelling will cause an increase in the symptoms of fatigue, aching, and throbbing in the leg. These symptoms are made worse by a lack of muscular exercise, meaning the increased pain will lead to less activity, further exacerbating the symptoms in a depressive cycle.
When climbing stairs, the legs have to lift the body, increasing the strength required. When one goes upstairs, a force of two to three times our body weight is applied to every leg on the upward step. This is why someone with healthy legs can generally walk or run for miles, but notice a significant increase in fatigue and leg pain when they have to climb several flights of stairs. Unfortunately, this becomes even more difficult for someone with varicose veins. First, the calf is unable to fully contract against the vein due to oppositional pressure.
Impact on balance and stability
Research into the link between varicose veins and their effect on mobility is limited, though there is strong evidence to imply that the above-mentioned end-stage complications will lead to a greater impact on a patient’s mobility. The causes of stasis dermatitis, ulcers, and skin changes are shown to result in a general decrease in mobility due to increased pain, and the location of the sores often yield an inability to put weight on the affected limb. This decrease in mobility was evident in a case-controlled study of 102 patients, which used a mobility score to reveal that patients with severe chronic venous disease were largely affected in their mobility and physical health when compared with an age and sex-matched control group.
Venous insufficiency is a condition most commonly associated with varicose veins and is due to an improper functioning of vein valves in the leg, which normally act to return blood to the heart. When these valves fail, blood collects in the legs, and the increased hydrostatic pressure often leads to the further dilation and distension of the veins, exacerbating the problem. An important additional effect is the seepage of fluid into the surrounding tissues, leading to skin inflammation (known as stasis dermatitis) and, if left uncorrected, can cause more serious skin changes and sores known as venous ulceration. Chronic swelling and skin changes in the lower leg can predispose to more serious complications in the long term.
Impact of varicose veins on physical activity
Varicose vein sufferers may have their lifestyles significantly affected by the underlying venous disease. The symptoms caused by varicose veins may result in a less active lifestyle – a major contributor to heart disease and stroke. It is estimated that 80% of Americans do not get adequate exercise, and varicose vein patients frequently fall into this group. Leg pain and swelling with associated fatigue are common complaints among those with varicose veins. These symptoms make the thought of starting an exercise regimen difficult and when attempted, often not maintained. This is because exercise can initially worsen the venous-related symptoms and although in the long run offer some improvement, often this is not enough to keep the patient motivated to continue. Heavy and tired legs are also a common complaint in those with varicose veins and this may be present all the time or worsen with prolonged standing. This once again acts as a deterrent to exercise, as many activities require prolonged periods of weight bearing on the legs. The end result is that patients with varicose veins often live an increasingly sedentary lifestyle. There are some individuals with varicose veins who have no symptoms, however, they may still be deterred from exercise due to the appearance of their legs. This is a result of low self-esteem and embarrassment and as a consequence, these individuals will avoid exposing their legs in shorts or swimming attire. It is important for such patients to understand that participating in regular exercise is valuable and will, in fact, help prevent further progression of the disease.
Limitations in exercising
Financial limitations also affect exercise capacity. The elderly population is especially limited by this, as a lot of insurance companies will not cover the costs of physical therapy sessions. This often leads to decreased participation in sports and recreational activities in an effort to save money. However, it is well recognized that regular exercise is beneficial to overall health and well-being. Patients who can no longer participate in high-impact sports such as basketball have the option to participate in lower-impact activities such as cycling or swimming. Although this may be beneficial to symptoms, it will do little to reverse the vein pathology.
Varicose veins often cause discomfort or pain, and patients with added difficulties such as swelling of the lower extremities may find it tough to stand for prolonged periods. This decreased capability to exercise often leads to obesity, which in turn leads to poor vein function. It becomes a self-perpetuating problem and the patient finds it tough to reverse. Intermittent claudication and ankle swelling, especially following prolonged periods of standing, are common symptoms among patients with varicose veins, and these symptoms limit the patient’s capability to complete activities involving long periods of standing or walking.
Decreased participation in sports and recreational activities
The study involved men and women ranging between the ages of 17-79, with the majority of them being within the working age range of 20-64. It was a focused study that hoped to get a good view of how detrimental VV can be to an individual’s life and whether certain treatments can prevent limitation of the individual’s social and work activities. This study provided good background information for health status and how limitation of social and work activity can be detrimental to quality of life.
This conclusion was reached by Bergan, S, and Kistner, R.L based on a study that took place in 30 municipal medical practices and involved 600 male and female patients with VV. This is a difficult aspect that can severely affect the individual’s quality of life. Recreation, hobby, and sports are essential activities for relieving tension, stress, and improving mental health. Many athletic activities can also provide the recommended exercise that the patient is missing out on due to avoidance of exercises which may exacerbate their VV.
Patients with VV have also been found to avoid certain activities which require prolonged periods of standing or sitting, the primary symptoms of VV. Patients reported decreased participation in sports and recreational activities in 24% of correspondents matched for age and sex with those not reporting venous disease.
Management and prevention strategies
Compression therapy is an effective measure to manage symptoms of venous disease. The use of compression bandage or stocking adds pressure to the distended vein thus increasing velocity and improving venous return. The pressure gradient and type of the compression stocking determine the therapeutic effects of compression therapy. A study compared the effects of different compression stockings in relieving symptoms of varicose veins. They found that stockings with a higher pressure gradient can reduce leg edema and symptoms of chronic venous disease. However, compression therapy only improves symptoms and quality of life but does not hinder the progression of venous disease. Compression stockings need to be worn most of the time. Compliance with compression therapy is essential because discontinuation of its use can exacerbate edema and symptoms.
Lifestyle modification is the first line management in preventing varicose veins progression and complications. It has been considered to manage the disease properly. The use of compression stockings at its early stage has been proven to alleviate symptoms such as leg pain, swelling, and heaviness. In general, patients can perform their usual activities of daily living without significant limitation. Weight reduction in obese or overweight patients also affects the disease. Weight reduction is recommended to alleviate symptoms and reduce venous disease progression. A study suggests that regular leg elevation is helpful to reduce leg edema, leg pain, and improve general health of patients with chronic venous disease. Regular leg elevation can also be an alternative method to prevent and alleviate symptoms of varicose veins. It can be performed in sitting or supine position with elevation of the affected leg to the level above the heart. In this position, gravity can help reduce leg edema. Patients with occupations that demand prolonged standing or sitting should change their working position regularly and take short rest in between. suggests that reducing sitting and standing times and regular foot exercise can delay the occurrence of telangiectasis. Step aerobic exercise does not affect the progression of varicose veins or venous disease. The exercise apparatus can be modified to eradicate exercise causative to varicose veins appearance or symptoms. However, beware of exercises that put excessive strain on the legs and increasing intra-abdominal pressure such as weight lifting and high-impact sports which may exacerbate the disease. Generally, regular lower limb exercises can improve calf muscle pump function and venous return. For Australian patients, has developed a guideline for a safe and effective lower limb exercise program for patients with varicose veins and venous disease.
Lifestyle modifications
Lifestyle advice should be given to patients who have varicose veins, especially those who are at risk of obtaining complications such as venous leg ulcers. People who are overweight or obese are advised to lose weight because being overweight can cause an increase in venous pressure, and studies have shown that a small reduction in body weight can cause a considerable reduction in venous distensibility and reflux. People who have jobs that involve long periods of standing or sitting are advised to reduce frequent periods of rest by changing position and walking around because although there is no definite evidence, prolonged standing or sitting have been associated with the development of varicose veins.
Varicose veins can be prevented or managed by lifestyle changes, with the aim of preventing the veins from getting worse, relieving the symptoms such as pain and swelling, and preventing complications. The National Institute for Health and Clinical Excellence (NICE) produced guidelines on managing varicose veins, and these are often the basis of how healthcare professionals advise people to prevent or slow down the progression of varicose veins. A Cochrane review of the effectiveness of the NICE guidelines concluded that there is little evidence to show that they are effective in preventing the progression of varicose veins or reducing symptoms and complications. However, a later publication concluded that the clinical guidelines are based on the best available evidence, and also expert opinion, and they provide a systematic method for healthcare professionals to advise patients on how to manage their varicose veins.
Compression therapy
Compression therapy is a longstanding strategy to manage venous insufficiency. The principle benefits of using compression therapy are to counter the increase in ambulatory venous pressure, which is the main cause of varicose vein development and its progression. It also helps to reduce the widespread capillary filtration that causes the medial ankle pigmentation often seen in individuals who have suffered with long-standing varicose veins. Elastic compression stockings are reported to alleviate the symptoms of varicose veins and also reduce their progression. Long and short stretch bandages were also widely used in the past to promote venous emptying; however, more recently it has been reported that multilayer, high compression bandage systems are an effective means to heal venous ulceration. This is, at least in part, due to the bandages providing a sustained raise in pressure. Although compression therapy in all forms is advocated for treating varicose veins, medical hosiery and stockings are often the preferred choice due to aesthetics and patient compliance. Unfortunately, compression therapy alone cannot correct underlying veins or faulty valves, and once discontinued, symptoms often recur.
Surgical interventions
From a scientific perspective, it is interesting to note that current research is comparing the effectiveness of surgical and conservative strategies to both placebo and each other. The COST trial compared early surgery with compression in order to ascertain which treatment was better for improving healing rates and reducing recurrence of venous leg ulcers. In conclusion, the study found no significant difference in ulcer recurrence rates after surgery or those that wore compression stockings. The surgery group had faster rates of ulcer healing; however, time to complete ulcer healing was not significantly different. Finally, surgical patients had higher quality of life scores compared to those who just wore stockings.
The National Institute for Clinical Excellence (NICE) clinical guideline for varicose veins (CG83) recommends endothermal ablation techniques (lasers or radiofrequency), foam sclerotherapy, ligation and stripping of the saphenous vein, and avulsion for management of varicose veins. This is on the proviso that the procedure used is under local anaesthetic and that the vein being treated has a straight, uncomplicated reflux resulting from a sapheno-femoral or sapheno-popliteal junctional reflux.
Surgical management of varicose veins has been traditionally considered an appropriate strategy for those with the severest forms of the condition. Surgery may be recommended for a variety of reasons, the most important being the treatment of venous leg ulceration or preventing its initial development. Other reasons include treatment of severe symptoms, prolonging the duration of a patient’s active life, prevention of disease progression, and improved cosmetic outcome.
