**2. Health and social impact of CVD**

#### **2.1. Epidemiology**

This chapter will address the role of physical therapists in the management of CVD. The chapter will begin by reviewing the basic physiopathology of CVD, including the role of calf muscle pump. The CEAP classification system and the chronic venous severity score will be presented, as these are main tools for clinical assessment of CVD severity. In the remainder of the chapter will address the physiological effects and recommendations for

treating CVD of MLD, based on our clinical experience and own research.

drainage

144 Clinical Physical Therapy

**1. Introduction**

professionals [1].

been abandoned for years.

prevented or even receded [14].

treatments can be undertaken [15].

**Keywords:** chronic venous disease, edema, calf muscle pump, manual lymphatic

The term chronic venous disease (CVD) has been used to describe morphological and functional abnormalities of the venous system of extended duration that are manifested themselves by symptoms and/or signs that indicate the need for evaluation and care by health

Usually, symptoms of leg heaviness, fatigue, and pain are the first complaints referred by patients, which together with varicose veins are present both in mild and severe cases of CVD. These complaints combined with structural changes in superficial, visible veins strongly contribute to a negative self-esteem that also characterizes this disease [2–8]. The diminished health-related quality of life (HRQL) seen in CVD is well studied [2, 8–10]. This negative impact is so important that the previous view of this condition as an aesthetic problem has

The socioeconomic burden of CVD is very high. The indirect costs are substantial and are associated with the symptoms, functional impairment, emotional disturbances and negative impact in HRQL [11]. The direct costs of CVD treatment are almost entirely related to its high prevalence, morbidity, and chronicity [11, 12]. In developed countries, around 1–3% of the health costs are due to CVD [13]. However, when patients with less severe stages of the disease are diagnosed and treated early, the physiopathology course of the disease can be

The severity of CVD is nowadays evaluated based on a multifactorial concept of the disease and using the standardized CEAP (Clinical Etiological, Anatomical and Pathological) classification system. Having a good knowledge of this system is very important to all physical therapist and it is important that health professionals use the same nomenclature so that CVD

The treatment of patients with CVD might focus on both the symptoms and secondary changes of the disease, such as edema, skin and subcutaneous changes or ulcers. Usually, initial treatment of CVD patients involves a non-invasive, conservative treatment to reduce symptoms, treat secondary changes, and help prevent the development of secondary complications and the progression of the disease. Complementary, some interventional or surgical

severity can be accurately assessed and the best treatment delivered [15].

Chronic venous insufficiency, represents the most severe cases of CVD, and its physiopathology is associated with venous hypertension, vein valve damage, venous obstruction, calf muscle pump impairment, inflammation of tissues (skin, subcutaneous tissue, and muscle) and veins, alteration of veins morphology and function. This disease is characterized by abnormal venous reflux, venous edema, and changes of the skin and subcutaneous tissue, with ulcer representing the most severe stage of this condition, and is classified between C<sup>0</sup> (no signs) and C6 (active ulcer) CEAP classes [13, 27–32]. Despite some controversies, CVD might exist without the presence of signs [3, 13, 33].

The estimated prevalence of CVD varies according to its severity, being around 10, 9, 1.5, and 0.5% for CEAP clinical levels C3 (venous edema), C4 (hyperpigmentation or eczema, lipodermatosclerosis, or atrophie blanche), C5 (healed venous ulcer), and C6 (active venous ulcer), respectively [33]. The more advanced stages of venous disease, (C3 –C6 ), appear to affect about 5% of the population [1]. Milder CVD conditions, like telangiectasiae and reticular veins (C1 class), have been reported to affect up to 80% of the population, while the incidence of varicose veins (C2 class) has been reported as ranging from 20% to 64% [1].

Despite its frequency in the population, the prevalence of CVD is still underestimated. Epidemiological data estimate a wide range of CVD prevalence, varying between 1-17% in men and 1-40% in women [34]. In the USA alone, approximately 2.5 million people suffer from CVD [2]. Variation in estimations of CVD prevalence are likely explained by differences in gender, age, ethnic group, risk factors and variations in diagnostic criteria and methods [1, 34]. A study where 91545 participants were evaluated, found a CVD prevalence of 83.6%, with 63.9% of the subjects classified as C1-C6, and 19.7% as C0. Regarding CVD prevalence according to gender, this study showed higher number of men in C0 class, higher number of women in C1-C3 classes and equal number of men and women in the more severe groups (C4-C6 class) [35]. Considering only the cases of varicose veins (C2), prevalence has been shown to vary in the range 7-40% in men and 25-32% in women [34].

#### **2.2. Functional and HRQL implications of CVD**

Patients with CVD display impaired functional capacity [2, 36] and diminished HRQL [9, 10, 37, 38]. The severity of CVD, HRQL scores, the clinical signs, and venous ultrasound findings of the disease are usually correlated [39].

The impact of CVD on HRQL is primarily seen in the physical items and in the emotional domain, but in its severest stages (presence of venous ulcers) the mental dimension might also become involved [9]. The impact of severe CVD in HRQL is similar to that of other chronic diseases, such as diabetes, cancer, chronic pulmonary disease, and heart failure [9].

Most of chronic leg ulcers are venous in origin [40]. Patients with venous ulcer present severe pain, which is in relationship with impaired tissue healing ability, diminished HRQL, lowered self-esteem, and poor social interactions [2]. The psychological effects of CVD may be not strictly related with ulceration itself but can else be associated with the symptoms caused by this type of wound (80.5-69.4%), altered appearance and esthetical concerns (66.7%), lack of sleep (66.6%), functional impairment (58.3%), and disappointment with treatment outcomes (50%) [2]. Also, patients with uncomplicated varicose veins often have severe symptoms that adversely affect their HRQL, irrespectively of the severity of the disease, refuting the view that this disease is mostly an aesthetic problem [8]. Estimates indicate that near 30% of patients with symptomatic varicose veins, who may not have had their clinical venous condition diagnosed or treated, display symptoms suggestive of a depressive illness [41].

In this disease, 49% of men and 62% of women have symptoms related to CVD [33], like pain, itching, tingling, cramps, restless legs, swelling, heaviness, and fatigue [3, 8]. A recent survey reveals that 14.9% of the general Greek population refers symptoms and/or present signs related to CVD [42].

The number of symptoms reported by patients with CVD varies but are usually several [4, 5, 8]. Importantly, the number and severity of symptoms are not strictly related to CVD severity and, sometimes, strong symptoms, and those that have the largest impact on HRQL, are present in less severe cases [8]. Nevertheless, despite possible indication for surgery, some studies suggest that the majority of the symptoms in patients with varicose veins are nonvenous related [5]. Indeed, it seems very difficult to separate venous from nonvenous causes of symptoms in CVD [6].

Several studies show the presence of both neuropathic and nociceptive pain in patients with CVD [4, 43]. Nevertheless, patients with CVD may present other comorbidities that make it difficult to isolate the CVD-related pain [43, 44].

Approximately one-third of people with CVD report to be a burden going out of home and participating in social events, and that they avoid wearing clothes exposing their legs or going on vacations to very warm places [42]. According to self-reports, functional status is diminished in these patients [36, 39] also because of some physical dysfunctions, like abnormalities in gait [45], impaired balance, peripheral neuropathy [43, 46] weak leg muscles (plantar flexion and dorsiflexion muscles) [29, 30, 45], or diminished ankle range of motion [10, 30, 47]. These dysfunctions are also associated with impaired muscle pump function in the lower extremity [43], an important risk factor for venous ulceration [48].

#### **2.3. Socioeconomic impact of CVD**

from CVD [2]. Variation in estimations of CVD prevalence are likely explained by differences in gender, age, ethnic group, risk factors and variations in diagnostic criteria and methods [1, 34]. A study where 91545 participants were evaluated, found a CVD prevalence of 83.6%, with 63.9% of the subjects classified as C1-C6, and 19.7% as C0. Regarding CVD prevalence according to gender, this study showed higher number of men in C0 class, higher number of women in C1-C3 classes and equal number of men and women in the more severe groups (C4-C6 class) [35]. Considering only the cases of varicose veins (C2), prevalence has been shown to

Patients with CVD display impaired functional capacity [2, 36] and diminished HRQL [9, 10, 37, 38]. The severity of CVD, HRQL scores, the clinical signs, and venous ultrasound findings

The impact of CVD on HRQL is primarily seen in the physical items and in the emotional domain, but in its severest stages (presence of venous ulcers) the mental dimension might also become involved [9]. The impact of severe CVD in HRQL is similar to that of other chronic

Most of chronic leg ulcers are venous in origin [40]. Patients with venous ulcer present severe pain, which is in relationship with impaired tissue healing ability, diminished HRQL, lowered self-esteem, and poor social interactions [2]. The psychological effects of CVD may be not strictly related with ulceration itself but can else be associated with the symptoms caused by this type of wound (80.5-69.4%), altered appearance and esthetical concerns (66.7%), lack of sleep (66.6%), functional impairment (58.3%), and disappointment with treatment outcomes (50%) [2]. Also, patients with uncomplicated varicose veins often have severe symptoms that adversely affect their HRQL, irrespectively of the severity of the disease, refuting the view that this disease is mostly an aesthetic problem [8]. Estimates indicate that near 30% of patients with symptomatic varicose veins, who may not have had their clinical venous condi-

diseases, such as diabetes, cancer, chronic pulmonary disease, and heart failure [9].

tion diagnosed or treated, display symptoms suggestive of a depressive illness [41].

In this disease, 49% of men and 62% of women have symptoms related to CVD [33], like pain, itching, tingling, cramps, restless legs, swelling, heaviness, and fatigue [3, 8]. A recent survey reveals that 14.9% of the general Greek population refers symptoms and/or present signs

The number of symptoms reported by patients with CVD varies but are usually several [4, 5, 8]. Importantly, the number and severity of symptoms are not strictly related to CVD severity and, sometimes, strong symptoms, and those that have the largest impact on HRQL, are present in less severe cases [8]. Nevertheless, despite possible indication for surgery, some studies suggest that the majority of the symptoms in patients with varicose veins are nonvenous related [5]. Indeed, it seems very difficult to separate venous from nonvenous causes of

vary in the range 7-40% in men and 25-32% in women [34].

**2.2. Functional and HRQL implications of CVD**

of the disease are usually correlated [39].

146 Clinical Physical Therapy

related to CVD [42].

symptoms in CVD [6].

Severe CVD has a significant economic impact, mostly due to raised morbidity. Over the last decade, neither CVD-associated and inflation-adjusted mean hospital charge, nor length of hospital stay decreased, possibly as a result of poor advancements in prevention and treatment of this disease [49]. It is estimated that 4.6 million of working days per year are lost as a result of CVD [40]. Painful leg ulcers, the odor, the dressing, the frequent need for treatment, with their associated restrictions and social isolation result in a heavy psychosocial burden [50]. In severe CVD, venous ulcers require wound care, compression, chemical and mechanical debridement, and, in frequent cases, antibiotic therapy [49]. While ulcer treatment is usually done in outpatient settings, in some particularly critical situations it may require hospitalization [40]. Western European countries spend 1.5-2% of their annual health budget in the treatment of this disease [51]. The economic burden is not just associated with clinical visits and outpatient treatments, but also with travel time, loss of work hours for patients and family, and physiological impairment related to analgesic and antibiotic use [49]. Limb amputation is a radical outcome of this disease, although in many of cases these are also related to comorbidities, for instance diabetes and arterial vascular disease [49]. Other important complications, such as hemorrhage, thrombosis and pulmonary embolism, also compound the unhealthy profile of these patients [42]. Deep venous thrombosis may cause chronic conditions like post-thrombotic syndrome and CVD, increasing the costs of the treatment [49]. Preventing deep venous thrombosis and complications is one of the most important aims for reducing socio-economic burden associated to CVD [49].

The chronic nature of the problem results in long-term costs and the frequent recurrences, together with the poor effectiveness of current treatments, further expand the cost of this disease [40].

Despite its cost, the efficacy of the pharmacological treatment of CVD is usually poor, and should be combined with other strategies, such as the use of elastic garment compression [33]. Similar procedures are recommended following surgery and sclerotherapy, in which cases post-operative compression therapy and health education are crucial for treatment success [42, 52]. There are several risk factors associated with CVD that patients should be informed of by the health professionals, like the use of hormonal contraceptives by women, daily routines (sitting or standing), pregnancy, age, obesity and heredity factors (i.e., family history) [1, 37, 42, 49, 53]. Also important, advice regarding behavioral changes, engaging in so-called venous exercises and the proper use of the health care services, should be offered to CVD patients [42]. Getting the right advice from health care professionals is an important measure for preventing and managing CVD [42].

Because of the wide spectrum of factors that cause functional impairment in these patients and the high costs of treatment [2, 3, 8], the prevention of CVD by educational and prophylactic interventions has been shown to be clinically cost-effective, by avoiding disease progression to the last stages [49, 54].
