**6. Clinical and functional assessment of CVD (CEAP classification, VCSS)**

#### **6.1. CEAP Classification**

Health professionals-reported outcomes, such as VCSS and CEAP classification, are convenient, easily evaluated, and relevant [15].

The CEAP classification was created to facilitate communication about CVD severity and for scientific research [13]. The CEAP classification was based on 1) clinical manifestations (C), 2) etiologic factors (E), described as congenital, primary, secondary (post-thrombotic), 3) anatomical distribution of disease (A), that can be located at superficial, perforator or deep veins, and 4) underlying pathophysiological findings (P), such as reflux, obstruction or both reflux and obstruction [13]. Subscripts are applied to designate S (symptomatic) from A (asymptomatic) limbs [65]. According to CEAP, there are six CVD categories that range from C0 to C6 [13, 65]. Also, the N subscript indicates no evidence of disease and is applicable to E, A, and/ or P of CEAP [13, 65].

The C0 represents those individuals with objective evidence of venous disease (i.e., E, A, and/ or P), but with no clinical manifestations. The C1 is characterized by the presence of telangiectasia or reticular veins (< 3mm in diameter). In the C2 class varicose veins (> 3 mm in diameter) are present. The C3 distinguishes itself from the preceding categories by the presence of edema of venous etiology. In the C4 class, there are now skin trophic changes, like C4a, for pigmentation and/or eczema, and C4b, for lipodermatosclerosis and/or white atrophy. Classes C5 and C6 are associated with the occurrence of venous ulcers: the C5 corresponds to cases of prior ulceration that healed, and C6 to cases with active venous ulcers [13, 65].

Reticular veins, also called blue veins, subdermal varices, and venulectasies, are dilated subdermal veins, usually 1 mm to less than 3 mm in diameter and with tortuous paths [13]. Telangiectasias, also called spider veins, hyphen webs, and thread veins, represent the confluence of dilated intradermal venules less than 1 mm in caliber [13].

exercise [104]. Such apparent calf pump dysfunction might be related to weak calf muscles in CVD patients [29, 30] and is compatible with a lower ejection volume, such as has been measured before in this population with air-plethysmography [92]. In addition, abnormal venous blood reflux from deep to superficial venous system through incompetent perforator veins

Nonetheless, it seems that calf muscle size is not a strong indicator of the efficacy of muscles to pump venous blood during contractions in patients with venous ulcer [105]. Also, gastrocnemius thickness and some other muscle architectural features, like pennation angle, are similar in patients with low to moderate CVD severity and healthy participants, and seem unrelated with the severity of CVD [104]. Despite this fact, for the medial gastrocnemius, a few morphological parameters (like higher muscle fascicle length, and pennation angle) are associated with the degree of increase in peak flow velocity in the popliteal vein during tip-toe

**6. Clinical and functional assessment of CVD (CEAP classification,** 

Health professionals-reported outcomes, such as VCSS and CEAP classification, are conve-

The CEAP classification was created to facilitate communication about CVD severity and for scientific research [13]. The CEAP classification was based on 1) clinical manifestations (C), 2) etiologic factors (E), described as congenital, primary, secondary (post-thrombotic), 3) anatomical distribution of disease (A), that can be located at superficial, perforator or deep veins, and 4) underlying pathophysiological findings (P), such as reflux, obstruction or both reflux and obstruction [13]. Subscripts are applied to designate S (symptomatic) from A (asymptomatic) limbs [65]. According to CEAP, there are six CVD categories that range from C0 to C6 [13, 65]. Also, the N subscript indicates no evidence of disease and is applicable to E, A, and/

represents those individuals with objective evidence of venous disease (i.e., E, A, and/

pigmentation and/or eczema, and C4b, for lipodermatosclerosis and/or white atrophy. Classes

Reticular veins, also called blue veins, subdermal varices, and venulectasies, are dilated subdermal veins, usually 1 mm to less than 3 mm in diameter and with tortuous paths [13].

are associated with the occurrence of venous ulcers: the C5

distinguishes itself from the preceding categories by the presence

to cases with active venous ulcers [13, 65].

is characterized by the presence of telangi-

class, there are now skin trophic changes, like C4a, for

class varicose veins (> 3 mm in diam-

corresponds to cases of

may blunt blood flow through the popliteal vein [104].

movement [104].

156 Clinical Physical Therapy

**6.1. CEAP Classification**

or P of CEAP [13, 65].

eter) are present. The C3

The C0

C5

and C6

nient, easily evaluated, and relevant [15].

or P), but with no clinical manifestations. The C1

of edema of venous etiology. In the C4

prior ulceration that healed, and C6

ectasia or reticular veins (< 3mm in diameter). In the C2

**VCSS)**

According to the guidelines, varicose veins (also called varix, varices, and varicosities [13]) should be palpable in an upright position and represent abnormal veins with at least 3 mm in diameter, [3, 13, 33]. Varicose veins can be present as a result of hypertension caused by reflux and/or obstruction, as discussed before [12, 57].

The development of varicose veins most frequently involves the saphenous veins, saphenous tributaries, or nonsaphenous superficial leg veins [13]. Varicose veins are usually tortuous, but tubular saphenous veins with demonstrated reflux may be classified as varicose veins [13]. Corona phlebectatica, also called malleolar flare and ankle flare, is commonly viewed as an early sign of CVD, and designates the accumulation of numerous small intradermal veins packed together on the medial or the lateral aspects of the ankle and foot [13].

The venous edema is a pitting edema that get worse through the day and static positions and improves at night with decrease hydrostatic pressure , accomplished for example in supine position and lower limb elevation, and usually is accompanied with venous symptoms and signs [19, 20].

The presence of pigmentation means that the skin becomes darker and brownish [13]. This results from extravasation of red blood cells into the interstitial space [57]. Blood extravasation and skin pigmentation is most noticed around the ankle, but may also be visible in the leg and foot [13, 106].

Atrophie blanche (white atrophy) is an induration of tissues This skin alteration, that should not be confused with healed venous ulcers, is usually well localized. and has the shape of a circular white and atrophic skin surrounded by dilated capillaries and sometimes by hyperpigmentation [13, 106].

Lipodermatosclerosis is also clinical sign of tissue induration, characterized by local chronic inflammation and fibrosis of skin and subcutaneous tissues at the lower region of the leg (also compromising the Achilles tendon), sometimes preceded by diffuse inflammatory edema of the skin, which may be painful and which often is referred to as hypodermitis [13, 106]. Clinically, lipodermatosclerosis must be differentiated from lymphangitis, erysipelas, or cellulitis by their characteristically different local signs and systemic nature characteristics [13].

The eczema is an inflammation process, erythematous dermatitis, which may progress to blistering, weeping, or scaling eruption of the leg skin, and may be located anywhere in the leg [13, 106]. Eczema is very frequent in uncontrolled CVD, but may also be associated to sensitization to local therapy [13].

Venous ulcers are the worst clinical sign of CVD and represent the loss of integrity of the skin, with a full-thickness defect and occur most frequently near the ankle region [13], at the site of major perforating veins and the greatest hydrostatic pressure [66]. Venous ulcers are also characterized by failure to heal spontaneously and are sustained by CVD [13].

The CEAP classification is the gold standard for classification of chronic venous disorders today and its use is recommended by the relevant guidelines [33]. Nevertheless, for proper use of CEAP some facts have to be taken into account: the CEAP classification is limited as a severity classification, C<sup>2</sup> summarizes all kinds of varicose veins, in C<sup>3</sup> it may be difficult to separate between venous and other reasons for edema, and corona phlebectatica is not included in the classification [107]. Further revisions of the CEAP classification may help to overcome the still-existing deficits [107]. Complementary to this classification system, some concepts were defined to give consistency to the scientific terms, like the CVD concept that designates any venous disorder associated to every clinical class, and the concept of chronic venous insufficiency, which represents the more severe stages of the disease (C3-6) [13, 65].

The CEAP classification is the gold standard for classification of chronic venous disorders today, and its use is recommended by the relevant guidelines [33]. Nevertheless, when using the CEAP system a few issues must be acknowledged: as a classifications system the CEAP has limitation. For example in C3 , it may be difficult to separate between venous edema from edema with other causes [106].

#### **6.2. Venous clinical severity score (VCSS)**

The Venous clinical severity score (VCSS) was developed to supplement the CEAP classification and to give an additional weight to the more severe consequences of CVD [108]. The VCSS score has shown good intra- and inter-observer reliability and responsiveness to change [108– 110]. This is a score that quantifies 10 items using the range: 0 (none), 1 (mild), 2 (moderate), and 3 (severe), with a total range score of 0–30 (best to worth) [106, 108–110]. In CEAP classes C0 to C6 , the VCSS score is reported to range between of 3–18 [111]. A worthwhile clinical improvement for patients with CVD can be observed with a relative improvement of 70% in VCSS score [110] or with an absolute improvement of 4 points [7]. Differences between clinical classes are 1–2 points of VCSS below C3 , and 2–5 points above C3 [111]. The items of the VCSS are:


• Active ulcers number

The CEAP classification is the gold standard for classification of chronic venous disorders today and its use is recommended by the relevant guidelines [33]. Nevertheless, for proper use of CEAP some facts have to be taken into account: the CEAP classification is limited as

to separate between venous and other reasons for edema, and corona phlebectatica is not included in the classification [107]. Further revisions of the CEAP classification may help to overcome the still-existing deficits [107]. Complementary to this classification system, some concepts were defined to give consistency to the scientific terms, like the CVD concept that designates any venous disorder associated to every clinical class, and the concept of chronic venous insufficiency, which represents the more severe stages of the disease (C3-6) [13, 65]. The CEAP classification is the gold standard for classification of chronic venous disorders today, and its use is recommended by the relevant guidelines [33]. Nevertheless, when using the CEAP system a few issues must be acknowledged: as a classifications system the CEAP

The Venous clinical severity score (VCSS) was developed to supplement the CEAP classification and to give an additional weight to the more severe consequences of CVD [108]. The VCSS score has shown good intra- and inter-observer reliability and responsiveness to change [108– 110]. This is a score that quantifies 10 items using the range: 0 (none), 1 (mild), 2 (moderate), and 3 (severe), with a total range score of 0–30 (best to worth) [106, 108–110]. In CEAP classes C0

, the VCSS score is reported to range between of 3–18 [111]. A worthwhile clinical improvement for patients with CVD can be observed with a relative improvement of 70% in VCSS score [110] or with an absolute improvement of 4 points [7]. Differences between clinical classes are

• Pain or discomfort; (i.e., aching, heaviness, fatigue, soreness, burning, with presumed venous origin), patients are asked to describe for each leg the category that best describes this

• Venous edema (presumed venous origin, i.e., pitting edema present every day and with significant changes by standing/limb elevation or evidence of venous etiology, like varicose veins or history of deep vein thrombosis) - clinical staff must exam both legs and should

• Skin pigmentation (presumed of venous origin and not including focal pigmentation over varicose veins or pigmentation due to other chronic diseases) - clinical staff must exam

• Inflammation (more than just recent pigmentation, like erythema, cellulitis, venous ecze-

• Induration (presumed of venous origin with secondary skin and subcutaneous changes, such as chronic edema with fibrosis, hypodermitis, white atrophy, and lipodermatoesclerosis);

, and 2–5 points above C3

• Varicose veins (with diameter ≤ 3 mm in standing position);

ask patients about the extent of edema experienced;

summarizes all kinds of varicose veins, in C<sup>3</sup>

, it may be difficult to separate between venous edema from

[111]. The items of the VCSS are:

it may be difficult

a severity classification, C<sup>2</sup>

158 Clinical Physical Therapy

has limitation. For example in C3

**6.2. Venous clinical severity score (VCSS)**

edema with other causes [106].

1–2 points of VCSS below C3

to C6

item;

each leg;

ma, dermatitis);


Despite their relevance, VCSS and CEAP evaluation can be biased by observer expectations and because patient-reported outcomes are recognized by medical authorities as the ultimate outcome for health-care interventions, self-reported assessment of symptoms and HRQL is recommended for CVD as well [15, 112]. The most comprehensively validated scales for assessing HRQL in CVD include the chronic venous insufficiency questionnaire (CIVIQ), for population with CVD and without ulcer; the Aberdeen varicose vein questionnaire (AVVQ), for population with varicose veins; and the venous insufficiency epidemiological and economic study on quality of life (VEINES-QOL), for population with CVD of all classes [113].
