**9. Treatment of CVI**

The initial management of CVI involves conservative approaches to reduce symptoms and prevent development of secondary complications and progression of disease. If conservative approaches fail or provide an unsatisfactory response, further treatment methods should be considered on the basis of anatomic and pathophysiologic features [40]. The treatment options of CVI ranges from simple compression stockings to very complicated venous reconstructions, and the most important step includes patient education to obtain better outcomes after treatment [5].

#### **9.1. Conservative treatment**

Conservative approaches aim mainly to restore the altered physiological functions of the venous system. It includes the elevation of the limb together with the supportive methods, pharmacotherapy and structured exercise program, as well as complex decongestive physiotherapy (CDP), intermittent pneumatic compression (IPC), compression stocking, patient training [41–44] and kinesio tape [45].

In order to overcome the effects of the gravity, the elevation of the limb in venous diseases has been applied for centuries. The venous pressure in the tissues around the ankle falls to approximately zero when the feet are at/above the heart level (i.e. toes-above-nose position). When the patient is in this position, all the signs and symptoms, which are directly associated with venous hypertension (i.e. ulcers, eczema, swelling, etc.), resolve without the need for any other treatment, particularly, in lower severity of disease [44].

Training the patient about the changes in lifestyle is important side of the total care. The control of weight, care of the limbs and optimum exercises to keep the calf muscles and ankle joint supple are among the strategies [44].

Compression is advised for the purpose of decreasing ambulatory venous hypertension in patients who have CVI. Changes in lifestyle including weight loss, exercise and elevation of the legs during the day whenever possible are also advised for such patients [46].

#### *9.1.1. Complex decongestive physiotherapy*

Since CVI includes combined formats of lymphedema, compression therapy (CT) is preferred as treatment method especially for advanced stages of CVI. CDP is a treatment program consisting of two phases. First phase is the phase in which the edema is decreased and lasts for 4 or more weeks and consists of four components as follows: (1) manual lymph drainage (MLD), (2) skin care, (3) compression bandage and (4) therapeutical exercises. The second phase is the one in which the decreased volume is protected with skin care, compression stocking and exercises. The precautions and patient training are emphasized for the extremity care for this program. The participation and harmony of the patient within the program are important for successful results [47].

#### *9.1.1.1. Manual lymphatic drainage*

To complement the CEAP classification and further define the severity of CVI, the venous clinical severity score (VCSS) was developed (**Table 2**) [36, 37]. The revised VCSS provides clarification of the terms and better definition of the descriptors and has further clinical applicability [38]. The VCSS consists of 10 attributes with four grades (absent, mild, moderate and severe). It has been shown to be useful in evaluation of the response to treatment in CVI. To evaluate severity of disease and treatment outcomes in CVI, it is recommended to make use of validated disease-

The initial management of CVI involves conservative approaches to reduce symptoms and prevent development of secondary complications and progression of disease. If conservative approaches fail or provide an unsatisfactory response, further treatment methods should be considered on the basis of anatomic and pathophysiologic features [40]. The treatment options of CVI ranges from simple compression stockings to very complicated venous reconstructions, and the most important step includes patient education to obtain better outcomes after treatment [5].

Conservative approaches aim mainly to restore the altered physiological functions of the venous system. It includes the elevation of the limb together with the supportive methods, pharmacotherapy and structured exercise program, as well as complex decongestive physiotherapy (CDP), intermittent pneumatic compression (IPC), compression stocking, patient

In order to overcome the effects of the gravity, the elevation of the limb in venous diseases has been applied for centuries. The venous pressure in the tissues around the ankle falls to approximately zero when the feet are at/above the heart level (i.e. toes-above-nose position). When the patient is in this position, all the signs and symptoms, which are directly associated with venous hypertension (i.e. ulcers, eczema, swelling, etc.), resolve without the need for any

Training the patient about the changes in lifestyle is important side of the total care. The control of weight, care of the limbs and optimum exercises to keep the calf muscles and ankle

Compression is advised for the purpose of decreasing ambulatory venous hypertension in patients who have CVI. Changes in lifestyle including weight loss, exercise and elevation of

Since CVI includes combined formats of lymphedema, compression therapy (CT) is preferred as treatment method especially for advanced stages of CVI. CDP is a treatment program

the legs during the day whenever possible are also advised for such patients [46].

specific quality-of-life questionnaires in clinical evaluations [39].

**9. Treatment of CVI**

128 Clinical Physical Therapy

**9.1. Conservative treatment**

training [41–44] and kinesio tape [45].

joint supple are among the strategies [44].

*9.1.1. Complex decongestive physiotherapy*

other treatment, particularly, in lower severity of disease [44].

Manual lymphatic drainage (MLD) is defined as a special manual technique stimulating the superficial lymphatic vessels in order to remove the excessive interstitial fluid [48] and to increase the lymph flow [49]. It has been used for more than 50 years as a type of conservative treatment method in CVI for the purpose of removing extremity edema [50]. In the origin of the technique, there is a soft massage for the purpose of stimulating lymphatic vessels and propel fluid through the channels. Since 20% (or more) patients, who have CVI, also have a lymphedema component, manual lymphatic drainage might have a significant role in a compression therapy program intended for CVI [51]. There have been four MLD techniques well known in the literature, up to now. These include the Foldi, Vodder, Casley-Smith and Leduc techniques [46].

In the study conducted by Foldi et al., it was reported that the MLD was inadequate without using compression therapy [52]. Similarly, Ochalek suggested that the use of compression therapy with MLD was necessary to sustain the effects of MLD [53]. In another study conducted by Bakar et al., 62 patients who had chronic venous disease were included and all the patients treated with CDP. According to the results of the study, CDP application decreased the volume and the percentage-volume of CVI-related edema at a significant level and decreased the intensity of the pain, which was caused by this condition, in the elderly [54].

While it is reported in a meta-analysis study conducted by Karki et al. that MLD was not significantly effective in sustaining decreased edema when used alone [55], Szewczyk et al. reported that MLD was effective in decreasing the edema in the lower limbs of the patients with CVD [56].

#### *9.1.1.2. Skin care*

Since CVI is a progressive disease, it disrupts the skin integrity. In healthy skin, the hydrolipid mixture consisting of water and lipid in the epidermis cover and protect the skin from external effects. The lipid component in it decreases the vaporization of the water and ensures the flexibility of the skin. Acidic products (pH 4.5–5.7) and microbial CVI may damage the skin integrity at further stages especially in internal malleoli area. There will be cracks and, in the end, inclination to infection occurs. In order to decrease the risk of infection and the disruption on the skin integrity, it is important to keep the skin moist in the affected area. For this reason, natural products that have balanced contents and that are similar to dermal lipids must be used. Normal skin moisture factors and the lipids that form barriers are important to keep the skin in elastic and slippery form. The applications that are healing and protective are important for both phases of the CDT. In Phase 1, the focus is on healing and care of the damaged skin. In Phase 2, the sustaining of the skin care is important [47].

#### *9.1.1.3. Compression*

The limb compression descriptions are to be found in *Corpus Hippocraticum* (450–350 BC) and it is known to be a major milestone in venous insufficiency treatment [51]. Compression treatment is an important part of the two phases of the CDP. During Phase 1, it is necessary to use the compression bandages for 23 hours a day. The purpose of the bandages is to have a certain form of the edema, and decrease the volume in the extremity. During Phase 2, compression is ensured with the compression stockings produced considering the size of the person [47].

The constriction of the leg veins is an essential mechanism of Compression Therapy (CT). In the supine position, a reduction in vein diameter accelerates blood flow velocity and also helps to prevent deep vein thrombosis. In the upright position, external compression is supposed to counteract the hydrostatic pressure. Due to the effect of gravity, external high pressures are required to maintain the same effect in standing position. It can be achieved with high pressure bandages to reduce ambulatory venous hypertension in patients with CVI [57].

The external pressure of approximately 30–40 mmHg is required to constrict the leg veins in the upright position. Complete occlusion of the leg veins occurs at a pressure of 20–25 mmHg in the supine position, at a pressure of 50–60 mmHg in the sitting position and at a pressure of approximately 70 mmHg in the standing position [57].

The treatment aims to correct the long-term complications of CVI at the possible highest level. CT increases pressure on the skin and on the underlying structures to react with the gravity force when it is applied in an external manner to the leg, which may help to relieve the symptoms in the lower limbs by affecting the venous and lymphatic systems to improve the removal of the fluid (i.e. the blood and the lymph) from the relevant limb [51].

The aims of CT may be summarized as follows:


In order to treat or prevent the adverse effects, the topical CT provides help. Limb compression changes the tissue pressure gradient, which, in return, reduces the formation of the edema and increases the resorption of the edema; reduces the vein caliber and increases venous flow velocity; reduces orthostatic reflux, residual volume and ambulatory venous pressure (partly by re-recruiting venous valves and by reducing reflux in the perforating vessels) and improves the muscle pump effectiveness [51].

There are many methods in the field of providing CT. The four-layer elastic bandaging (4LB) and the short stretch bandaging (SSB) are the most widely used techniques. The introduction of the graded compression stocking in varying degrees of pressures at the ankle area is a major advance in CT. The purpose of these systems is to provide graduated compression to the lower limb for the purpose of improving venous return and to reduce the edema [51]. Different ambulatory compression techniques and devices cover the compression stockings (CS), paste gauze boots (i.e. the Unna boot), multilayer elastic wraps, dressings, elastic and non-elastic bandages and non-elastic garments. Pneumatic compression devices are also used in patients with refractory edema and venous ulcers [58].

#### *9.1.2. Compressionv stocking*

for both phases of the CDT. In Phase 1, the focus is on healing and care of the damaged skin. In

The limb compression descriptions are to be found in *Corpus Hippocraticum* (450–350 BC) and it is known to be a major milestone in venous insufficiency treatment [51]. Compression treatment is an important part of the two phases of the CDP. During Phase 1, it is necessary to use the compression bandages for 23 hours a day. The purpose of the bandages is to have a certain form of the edema, and decrease the volume in the extremity. During Phase 2, compression is ensured with the compression stockings produced considering the size of the person [47]. The constriction of the leg veins is an essential mechanism of Compression Therapy (CT). In the supine position, a reduction in vein diameter accelerates blood flow velocity and also helps to prevent deep vein thrombosis. In the upright position, external compression is supposed to counteract the hydrostatic pressure. Due to the effect of gravity, external high pressures are required to maintain the same effect in standing position. It can be achieved with high pressure

The external pressure of approximately 30–40 mmHg is required to constrict the leg veins in the upright position. Complete occlusion of the leg veins occurs at a pressure of 20–25 mmHg in the supine position, at a pressure of 50–60 mmHg in the sitting position and at a pressure

The treatment aims to correct the long-term complications of CVI at the possible highest level. CT increases pressure on the skin and on the underlying structures to react with the gravity force when it is applied in an external manner to the leg, which may help to relieve the symptoms in the lower limbs by affecting the venous and lymphatic systems to improve the removal

**2.** Maintain the limb at its possible smallest size by using the simplest methods that are

**3.** Allow the patient to participate in the care of the limb in an active manner by avoiding the

**4.** Train the patient on how to modify his/her own therapy method in case of a problem with

In order to treat or prevent the adverse effects, the topical CT provides help. Limb compression changes the tissue pressure gradient, which, in return, reduces the formation of the edema and increases the resorption of the edema; reduces the vein caliber and increases venous flow velocity; reduces orthostatic reflux, residual volume and ambulatory venous pressure (partly by re-recruiting venous valves and by reducing reflux in the perforating vessels) and improves

bandages to reduce ambulatory venous hypertension in patients with CVI [57].

Phase 2, the sustaining of the skin care is important [47].

of approximately 70 mmHg in the standing position [57].

The aims of CT may be summarized as follows:

factors that aggravate the edema.

the muscle pump effectiveness [51].

possible.

edema [51].

of the fluid (i.e. the blood and the lymph) from the relevant limb [51].

**1.** Decrease the swollen limb to its minimum size as fast as possible.

*9.1.1.3. Compression*

130 Clinical Physical Therapy

Compression stocking (CS) was first developed in the 1950s by Conrad JOBST. CS is available in various forms, force and size. It provides a pressure decreasing towards proximal from the distal and it has become one of the key treatments and standard procedure in the management of venous lymphatic disorders. Compression pressure ranges and the definition of these classes vary among countries. For this reason, using the pressure ranges as mmHg will be beneficial for universal understanding. CS is classified into four classes according to their pressure values (**Table 3**). The pressures of the CS used in CVI depend on the clinical severity; for CEAP second and third classes, 20–30 mmHg and for CEAP fourth to sixth classes, 40–50 mmHg are used. The most-frequently used size is the one that stretched up to the knee, because the patient participation is more and the symptom healing is adequate. The stockings that reach up to the thigh and groin may be compulsory for the patients that have edema on the knee; however, the use of such stockings is difficult. It must be changed every 6 months [5]. CS must be worn in the stages when the veins are at the emptiest stage. The CS that is worn in the early morning when the patient gets up is the most effective one. The patient must walk in the stockings during the day [40].

#### *9.1.3. Intermittence pneumatic compression (IPC)*

Wide consensus exists in the literature that compression is a necessary part of all treatments for CVI and venous ulcers. Compression is usually provided by stockings. Most of the elderly patients have reduced strength and skill and therefore it makes these stockings difficult to wear. Compression can also be provided with the Unna's boot or different types of bandages [27].

Extremity compression can be achieved with pneumatic compression tools. Pneumatic compression devices consist of an inflatable garment for the arm or leg and an electrical pneumatic pump that fills the garment with compressed air. The boot is intermittently inflated and deflated and creates a pumping effect [27]. The inflation and deflation cycles mimic the muscle pump. This is one of the key mechanisms to provide proper venous and lymphatic flow [59].


**Table 3.** Compression classes.

First generation pneumatic compression devices consisted of an inflatable single compartment pressure chamber that applied a non-segmented uniform and sustained level of compression to the entire extremity. Later, multi-segment compression devices were developed in order to increase the effectiveness of the devices. Thanks to these devices, technically, the pressure gradient is created between distal and proximal parts of the limb. The pressure of distal chamber is higher than in the proximal chamber and this enables a sequential mechanism of distal to proximal application of pressure. Pneumatic compression devices have further evolved in recent years and allow digital programming to imitate MLD techniques and promote fluid clearance at the proximal trunk and extremities [60] (**Table 4**).


**Table 4.** Pneumatic compression devices.

The most basic definition of the IPC is that it consists in the application of a force on an edema in order to evacuate its components as much as possible towards the physiological ways of drainage (venous—lymphatics—interstitium) [61].

IPC has physiological effects such as increase in capillary perfusion, increase in tissue oxygenation, increase in the fibrinolytic potential of endothelial cells, increased blood-flow in the deep veins, decrease in stasis, decrease in venous hypertension and decrease in interstitial edema [62–64].

There are some contraindications to pneumatic compression [65] (**Figure 1**). Despite the fact that there is no serious complication of pneumatic compression, It has been reported that there are some complications in the literature [27, 66, 67] (**Figure 2**).

In the study of Caprini, it was reported that pneumatic compression applied 4 hours per day provided significant improvement in symptoms [68]. Another study examined the efficacy of pneumatic compression in those with CVI and it was concluded that a single 30-min session per day of pneumatic compression decreased edema, increased venous blood-flow and improved symptoms [69].

**Figure 1.** Contraindications of IPC.

First generation pneumatic compression devices consisted of an inflatable single compartment pressure chamber that applied a non-segmented uniform and sustained level of compression to the entire extremity. Later, multi-segment compression devices were developed in order to increase the effectiveness of the devices. Thanks to these devices, technically, the pressure gradient is created between distal and proximal parts of the limb. The pressure of distal chamber is higher than in the proximal chamber and this enables a sequential mechanism of distal to proximal application of pressure. Pneumatic compression devices have further evolved in recent years and allow digital programming to imitate MLD techniques and

**Single chamber non-programmable pumps** • The single sleeve inflates to apply pressure on the leg

**Multi-chamber (segmented) non-programmable pumps** • Approximately three or four chambers swell complete-

**Multi-chamber programmable pumps** • The pressure gradient is set to be higher in the distal

**Advanced pneumatic compression systems** • Digitally programmable

**Table 4.** Pneumatic compression devices.

• No manual control on pressure distribution

• Nowadays it is not an optimal method for lymphede-

ly from the distal to the proximal segment and then

• Perhaps a limited pressure programming option can be found but not independently adjustable

• Structurally, each chamber is designed to reach the same pressure gradient, with support from the extrem-

• Pumps can use one or both of the same legs or arms

• It produces three different pressure zones, and some pumps allow the divider to set the pressure

• Manual programmable and pressure-adjustable for

• With proper application to adjoining trunk segments, it can provide a uniform distribution of edema by re-

• Garbage and proximal chambers can open lymphatic

• Only 1 and 2.5 compartments can actively simulate manual lymphatic drainage by providing a pressure increase and progression from distal to proximal

segment and lower in the proximal segment

• No pressure gradient

ma treatment

descend

ity shape

the desired zone

pathways

• Adjustable from 4 to 36 chambers

laxing the proximal and distal limb

promote fluid clearance at the proximal trunk and extremities [60] (**Table 4**).

**Pneumatic compression device Distinctive features**

132 Clinical Physical Therapy

**Figure 2.** Complications of IPC.

In the literature, it is common in CVI that high pressure is more effective compared to low pressure, multi-layer bandages are more effective compared to single-layer bandages and compression application is more effective than no compression application [63].

#### *9.1.4. Exercise*

The calf muscle pump is the basic mechanism in the return of blood from the lower extremity to the heart and also it is supported by the foot pump, the thigh pump and the respiratory pump. The ankle joint is the main component of the calf muscle pump. Therefore, dorsiflexion and plantar flexion of the ankle is the basis for effective function of the calf muscle pump [70, 71]. It is known that limited ankle mobility increases the severity of edema formation and venous reflux in patients with CVI. CVI causes ankle immobility due to storage of fibrotic tissue. Because of immobility, the calf muscle pump cannot be activated and venous blood does not return to the heart [72]. Presence of any abnormality in pump functions of calf muscle plays a significant role in the development of CVI. In patients with CVI, progressive exercise program have been used to rehabilitate the muscle pump function and improve symptoms [6]. A randomized controlled study designated individuals with advance venous disease (CEAP class C4–C6) to structured calf muscle exercise or routine daily activities. To assess venous hemodynamics duplex ultrasound and APG were used, and muscle strength was assessed with a dynamometer. After 6 months, parameters of pump function of calf muscles normalized in patients receiving customized exercise program for calf muscles. However, there was no change in the amount of reflux or severity scores. Although it was found that severity scores of reflux was not changing statistically, it appears that calf muscle pump function could be established by structured exercise in CVI that may prove effective as supplemental therapy to medical and surgical treatment in advanced disease [73].

Research over the past 10–12 years points to ankle joint movement as the key biomechanical element in a functioning calf pump. When artificially restricting the movement of the ankle joint in healthy volunteers, it is demonstrated that a significant decrease occurred in the efficiency of the pump to affect a decrease in venous pressure during exercise [74]. Calf muscle strength may also affect the efficiency of venous return [75]. An improvement in calf muscle strength correlates with improved venous return [76] and loss of muscle strength is seen in patients with long-lasting venous ulcer [75]. Taheri et al. stated that there are three types of atrophy in biopsies of the gastrocnemius muscle in patients with vein insufficiency. These were disuse, denervation and ischemia, which play a role in muscle destruction [77]. How much calf muscle volume contributes to venous insufficiency is unclear [75].

Back et al. stated that a normal walking motion is required for activation of the calf muscular pump and this requires 90 degrees of dorsiflexion [78]. It has been found that exercise program twice a week increased the angle of dorsiflexion and plantar flexion in those with CVI [79].

#### *9.1.5. Kinesio tape*

In the literature, it is common in CVI that high pressure is more effective compared to low pressure, multi-layer bandages are more effective compared to single-layer bandages and

Complicaons of IPC

Compartment syndrome

> Damage of peroneal nerve

> > Ulceraon on the skin

The calf muscle pump is the basic mechanism in the return of blood from the lower extremity to the heart and also it is supported by the foot pump, the thigh pump and the respiratory pump. The ankle joint is the main component of the calf muscle pump. Therefore, dorsiflexion and plantar flexion of the ankle is the basis for effective function of the calf muscle pump [70, 71]. It is known that limited ankle mobility increases the severity of edema formation and venous reflux in patients with CVI. CVI causes ankle immobility due to storage of fibrotic tissue. Because of immobility, the calf muscle pump cannot be activated and venous blood does not return to the heart [72]. Presence of any abnormality in pump functions of calf muscle plays a significant role in the development of CVI. In patients with CVI, progressive exercise program have been used to rehabilitate the muscle pump function and improve symptoms [6]. A randomized controlled study designated individuals with advance venous disease (CEAP class C4–C6) to structured calf muscle exercise or routine daily activities. To assess venous hemodynamics duplex ultrasound and APG were used, and muscle strength was assessed with a dynamometer. After 6 months, parameters of pump function of calf muscles normalized in patients receiving customized exercise program for calf muscles. However, there was no change in the

compression application is more effective than no compression application [63].

*9.1.4. Exercise*

Sweang and fever under the glove

134 Clinical Physical Therapy

**Figure 2.** Complications of IPC.

Genital lymphedema

> Kinesiology taping (Kinesio Tape) which was developed by Dr. Kenzo Kase in 1996 is a technique that is used to restore muscle function, to increase vascular and lymphatic circulation, to relieve pain or to correct the impaired joint alignment. Kinesio Tape is an elastic, latex-free, adhesive and waterproof tape. Moreover, it is an application that may remain in the skin for 3–5 days. Skin adhesive tape is thicker and more elastic than conventional tape and also it has the ability to stretch up to 120–140% of its normal length. Although there is no definite evidence for its proprioceptive effect, it is thought to act by means of cutaneous mechanoreceptors [80].

> Skin-taping increases the circulation in the region by creating convulsions that cause the dermis to rise up. Kinesio Tape, which is frequently used in edema, hematoma and wound healing, has been used as an alternative to compression therapy in patients with venous insufficiency in recent years. Even if it is frequently used, Kinesio Tape has not been proven to have a positive effect on venous insufficiency. In some studies, it has been shown that there was an increase in lymphatic circulation and venous return of individuals who underwent fan technique without strain [81].
