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CASE REPORT
Ahead of print publication  

Role of physiotherapy interventions in treating varicose veins


 Department of Physiotherapy, Lovely School of Physiotherapy, Lovely Professional University, Phagwara, Punjab, India

Date of Submission02-Nov-2020
Date of Decision20-May-2021
Date of Acceptance21-May-2021

Correspondence Address:
Rachna Shah,
Lovely School of Physiotherapy, Lovely Professional University, Phagwara, Punjab
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_605_20

  Abstract 


The lower limb venous system is responsible for returning blood from the foot, leg, and thigh toward the heart. Chronic venous disease occurs by an inability of the blood to completely return due to structural or functional abnormalities of the veins of the lower limbs. Varicose veins are enlarged veins that have become tortious and abnormally swollen. This study was taken to evaluate, diagnose, and rehabilitate varicose veins by physiotherapy interventions. The patient presented at our outpatient department with severe varicose veins. She was assessed, and a patient-specific 2-month rehabilitation program was formulated. This study helps us to understand various aspects involved in the condition, its prognosis, and management by physiotherapy interventions.

Keywords: Physiotherapy interventions, Trendelenburg test, varicose veins, venous filling time



How to cite this URL:
Shah R, Sadhu S. Role of physiotherapy interventions in treating varicose veins. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 7]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=340565




  Introduction Top


Varicose veins are enlarged veins that have become tortious and abnormally swollen. Chronic venous disease occurs by an inability of the blood to completely return.[1] The veins most commonly affected are those in our legs. Various factors such as occupations involving prolonged hours of standing, obesity, and family history lead to the development of varicose veins.[2]

There are very few studies that determine a rationale-based physiotherapy protocol for the treatment of this condition. Hence, this report is put forth to set a standard treatment protocol for the condition with proper rationale for each intervention and physiological changes that will be bought about by those interventions.


  Case Report Top


A 53-year-old female who was operated by vein ligation and stripping for varicose veins in left leg in October 2016 visited our outpatient department with chief complaints of leg pain and knee pain for 5–6 months along with the prominence of veins in both legs. She experienced throbbing and aching pain which was aggravated by standing for hours, long sitting, stair climbing, and walking more than 1 km. The intensity of this pain, as noted using the Numeric Pain Rating Scale (NPRS), was 8/10 during activity and 5/10 at rest in the right leg and 5/10 during activity, and 3/10 at rest for the left leg. She lived on the 2nd floor with no lift facility and hence had to climb 20–22 steps of average height daily.

The patient had antalgic gait and swelling in the left foot. Her cadence was reduced to 54 and BMI was calculated to be 26.25 which is overweight. She experienced Grade 2 tenderness in both legs. The movements of lower limb were found to be strong and painful. The patient's active hip flexion and extension ranges were reduced to 40° and 25°, respectively, on both sides. Hip abduction, adduction, and knee and ankle ranges were full. The strength for hip flexors, hip extensors, hip abductors, knee flexors, and knee extensors was 3/5 according to manual muscle testing grading on both sides. Core muscle testing revealed that upper abdominals had Grade 4 strength, lower abdominals had Grade 2, whereas the back strength was Grade 2. Her thoracic expansion and chest excursion were reduced at the nipple and xiphisternal level.

For diagnosing the condition, the venous filling time was noted which was calculated as 10 s. Hence, venous disease was suspected. Following this, the Trendelenburg test was done. The filling time was 43 s and veins appeared distended before the removal of the tourniquet. Hence, varicose veins were confirmed by the therapist. Considering all the history and assessment, a proper patient-specific intervention program was formulated for this patient by the therapist as shown in [Table 1].
Table 1: Physiotherapy intervention program designed for the patient

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This protocol was given for 2 months with progression in exercises when needed. At the end of 2 months, the enlarged veins were no longer of the same size, and also discolorations had reduced. The knee pain subsided completely and leg pain NPRS was reduced to 2/10 during activities and no pain at rest.


  Discussion Top


This study was done to formulate a well-established protocol in treating varicose veins and its physiological effects on the body. The therapist in this study first educated the patient about her condition and therapist goals in treating the same. The patient was also informed about the expected recovery time, and prior consent was taken. This was done to keep her motivated throughout the treatment. Patient education also allows the patient to get knowledge about disease management and hence adjust to the treatment protocol for betterment in quality of life.[3]

The patient was given ergonomic advice so that the patient would not undergo any aggravation in pain. By combining proper ergonomic advice with the treatment, the therapist can target both intrinsic and extrinsic factors causing the discomfort.[4] Since the patient was overweight, weight management was done as overweight or obesity is one of the risk factors for a person with varicose veins. This is because the foot is too heavy to support the body and hence, veins need to work more effectively and more power is needed to pump blood toward the heart and hence higher chances of stasis of blood.[5]

For reduction of leg pain, contrast bath was used for alternate immersion in hot and cold baths for 15–20 min. This causes alternate vasoconstriction and vasodilation of the vessels by the modality and hence improves circulation and this, in turn, helps to reduce pain in case of varicosities.[6]

To improve circulation, low-level cold LASER was used for 10 min. This LASER works effectively for reducing pain by improving circulation and releasing nitric oxide in the microcirculation that would in turn prevent pain and comfort the patient. This also helps in lowering the level of biochemical markers and oxidative stressors.[7] Regular physical activity helps to maintain muscle tropism which is important to maintain the efficiency of the venous pumps, and hence the use of elastic varicose veins stockings during walking was encouraged as this increases venous working pressures between the skin and stocking.[8]

To improve circulation, Buerger's exercises were implemented in different positions of lower limb, in which gravity would assist blood flow. Ideally, 720 repetitions of ankle–toe movements are needed regularly to prevent stasis. Our protocol focused on performing 810 repetitions daily. This leads to the effective functioning of collateral circulation to prevent stasis. Studies have demonstrated that exercising enhances microvascular endothelial function, resulting in increased venous flow. Blood flow acceleration is due to muscular contractions that squeeze intermuscular veins and intramuscular venous networks. A coordinated chain of muscular pumps is sequentially activated during walking, and respectively, activating the plantar, calf, thigh, and gluteal pumps. Hence, toe walking and heel raises have shown effect.[9]

For reduction of knee pain and maintaining the strength of associated areas, isometric contractions of hamstrings, quadriceps, abductors, adductors, and gluteus muscles were performed. This causes recruitment of muscle fibers in response to increased intramuscular tension. Furthermore, 30% strengthening can be done with isometric recruitment of muscles as strong muscles protect the joint, and weak muscles lead to joint dysfunction and pain. Small amplitude oscillatory glides were given for pain management as they inhibit mechanoreceptors that transmit nociceptive stimuli to the spinal cord. The glides also improve nutrition to the joint and remove pain-causing enzymes.[10]

To improve thoracic mobility, trunk rotations and side flexions were done, 10 repetitions on each side. Along with this, the patient was taught diaphragmatic breathing to reduce the work of breathing and improve oxygenation to all parts of the lungs.


  Conclusion Top


Specific physiotherapeutic protocol was effective in the treatment of varicose veins for the case we presented. Protocol must be formulated with proper assessment before starting the treatment considering all factors associated. To the best of our knowledge, there are no published studies with a clear regimen to treat varicose veins, and hence this study would contribute to enhancing knowledge of health-care practitioners and students.

Acknowledgments

The authors of this study would like to thank the patient for her timely cooperation in conducting the study and following our instructions throughout the treatment regimen.

Patient consent

The authors of this study have explained the details of this study and need for publication to the patient and obtained a written consent before sending the article for publication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rutherford RB. In: Rutherford RB, editor. Chronic Venous Disorders: General Considerations. 8th ed. Philadelphia: WB Saunders; 2014. p. 843-56.  Back to cited text no. 1
    
2.
Shadrina AS, Sharapov SZ, Shashkova TI, Tsepilov YA. Large-scale genetic study provides new insights into genetics and etiology of varicose veins. Eur J Human Genet 2019;27:1331-2.  Back to cited text no. 2
    
3.
Stenberg U, Vågan A, Flink M, Lynggaard V, Fredriksen K, Westermann KF, et al. Health economic evaluations of patient education interventions a scoping review of the literature. Patient Educ Couns 2018;101:1006-35.  Back to cited text no. 3
    
4.
Tsang SM, So BC, Lau RW, Dai J, Szeto GP. Effects of combining ergonomic interventions and motor control exercises on muscle activity and kinematics in people with work-related neck-shoulder pain. Eur J Appl Physiol 2018;118:751-65.  Back to cited text no. 4
    
5.
Widyaningsih TS, Prabu Y, Kustriyani M. the level of obesity and the incidence varicose vein on adult patients in public health center Mijen. Aloha Int J Health Adv 2018;1:76-8.  Back to cited text no. 5
    
6.
Higgins TR, Greene DA, Baker MK. Effects of cold water immersion and contrast water therapy for recovery from team sport: A systematic review and meta-analysis. J Strength Cond Res 2017;31:1443-60.  Back to cited text no. 6
    
7.
Dima R, Tieppo Francio V, Towery C, Davani S. Review of literature on low-level laser therapy benefits for nonpharmacological pain control in chronic pain and osteoarthritis. Altern Ther Health Med 2018;24:8-10.  Back to cited text no. 7
    
8.
Cataldo JL, de Godoy JM, de Barros N. The use of compression stockings for venous disorders in Brazil. Phlebology 2012;27:33-7.  Back to cited text no. 8
    
9.
Caggiati A, De Maeseneer M, Cavezzi A, Mosti G, Morrison N. Rehabilitation of patients with venous diseases of the lower limbs: State of the art. Phlebology 2018;33:663-71.  Back to cited text no. 9
    
10.
Lee KS, Lee JH. Effect of maitland mobilization in cervical and thoracic spine and therapeutic exercise on functional impairment in individuals with chronic neck pain. J Phys Ther Sci 2017;29:531-5.  Back to cited text no. 10
    



 
 
    Tables

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