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Vascular physiotherapy: a strategy for treatment of chronic venous disease

Fisioterapia vascular: estratégia no tratamento da doença venosa crônica

Rodrigo Pegado de Abreu Freitas Georges Willeneuve de Souza Oliveira Maria Thereza Albuquerque Barbosa Cabral Micussi About the authors

We read with great interest the recent manuscript by Leal et al.11 Leal FJ, Couto RC, Silva TP, Tenório V. Vascular physiotherapy in treatment of chronic venous disease. J Vasc Bras. 2015;14(3):224-30. http://dx.doi.org/10.1590/1677-5449.0029.
http://dx.doi.org/10.1590/1677-5449.0029...
entitled “Vascular physiotherapy in treatment of chronic venous disease”. The authors investigate the results of a supervised rehabilitation protocol including warm-up, training and relaxation. The training protocol consisted of vascular kinesiotherapy using manual lymph drainage and resistance and aerobic exercises. The importance of this type of study is unquestionable since chronic venous disease (CVD) affects a considerable proportion of the worldwide population and can involve chronic wounds and disability.22 Lal BK. Venous ulcers of the lower extremity: definition, epidemiology, and economic and social burdens. Semin Vasc Surg. 2015;28(1):3-5. http://dx.doi.org/10.1053/j.semvascsurg.2015.05.002. PMid:26358303.
http://dx.doi.org/10.1053/j.semvascsurg....
This is an initial treatment for CVD and its aim is to reduce symptoms and help prevent the development of secondary complications and disease progression.33 Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2005;111(18):2398-409. http://dx.doi.org/10.1161/01.CIR.0000164199.72440.08. PMid:15883226.
http://dx.doi.org/10.1161/01.CIR.0000164...

However, another preliminary therapeutic option for all CEAP clinical classes of CVD is continuous compression therapy.33 Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2005;111(18):2398-409. http://dx.doi.org/10.1161/01.CIR.0000164199.72440.08. PMid:15883226.
http://dx.doi.org/10.1161/01.CIR.0000164...
In this case, the objective is to administer graded external compression to the leg, opposing the hydrostatic forces of venous hypertension.33 Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2005;111(18):2398-409. http://dx.doi.org/10.1161/01.CIR.0000164199.72440.08. PMid:15883226.
http://dx.doi.org/10.1161/01.CIR.0000164...
A number of compression garments are available including elastic compression stockings, multilayer elastic wraps, dressings, elastic and nonelastic bandages and nonelastic garments.33 Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2005;111(18):2398-409. http://dx.doi.org/10.1161/01.CIR.0000164199.72440.08. PMid:15883226.
http://dx.doi.org/10.1161/01.CIR.0000164...
The American College of Phlebology strongly recommends compression therapy as an effective method for the management of symptoms related to CVD.44 Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53(5, Suppl):2S-48S. http://dx.doi.org/10.1016/j.jvs.2011.01.079. PMid:21536172.
http://dx.doi.org/10.1016/j.jvs.2011.01....
These recommendations apply to most patients in most circumstances without reservations.33 Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2005;111(18):2398-409. http://dx.doi.org/10.1161/01.CIR.0000164199.72440.08. PMid:15883226.
http://dx.doi.org/10.1161/01.CIR.0000164...
,44 Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53(5, Suppl):2S-48S. http://dx.doi.org/10.1016/j.jvs.2011.01.079. PMid:21536172.
http://dx.doi.org/10.1016/j.jvs.2011.01....
It is clear that the results of the treatment protocol applied by Leal et al.11 Leal FJ, Couto RC, Silva TP, Tenório V. Vascular physiotherapy in treatment of chronic venous disease. J Vasc Bras. 2015;14(3):224-30. http://dx.doi.org/10.1590/1677-5449.0029.
http://dx.doi.org/10.1590/1677-5449.0029...
were good, but they could have been enhanced by addition of elastic compression stockings or nonelastic bandages worn during the exercise protocol and afterwards.55 Khilnani NM, Grassi CJ, Kundu S, et al. Multi-society Consensus Quality Improvement Guidelines for the Treatment of Lower-extremity Superficial Venous Insufficiency with Endovenous Thermal Ablation from the Society of Interventional Radiology, Cardiovascular Interventional Radiological Society. J Vasc Interv Radiol. 2010;21(1):14-31. http://dx.doi.org/10.1016/j.jvir.2009.01.034. PMid:20123189.
http://dx.doi.org/10.1016/j.jvir.2009.01...
Treatment with 30 to 40 mm Hg compression stockings results in significant improvement in pain, swelling, skin pigmentation, activity, and well-being if compliance of 70% to 80% is achieved.55 Khilnani NM, Grassi CJ, Kundu S, et al. Multi-society Consensus Quality Improvement Guidelines for the Treatment of Lower-extremity Superficial Venous Insufficiency with Endovenous Thermal Ablation from the Society of Interventional Radiology, Cardiovascular Interventional Radiological Society. J Vasc Interv Radiol. 2010;21(1):14-31. http://dx.doi.org/10.1016/j.jvir.2009.01.034. PMid:20123189.
http://dx.doi.org/10.1016/j.jvir.2009.01...
Compression stockings have been shown to reduce the residual volume fraction, which is an indicator of improved calf muscle pump function, and they also reduce reflux in vein segments.55 Khilnani NM, Grassi CJ, Kundu S, et al. Multi-society Consensus Quality Improvement Guidelines for the Treatment of Lower-extremity Superficial Venous Insufficiency with Endovenous Thermal Ablation from the Society of Interventional Radiology, Cardiovascular Interventional Radiological Society. J Vasc Interv Radiol. 2010;21(1):14-31. http://dx.doi.org/10.1016/j.jvir.2009.01.034. PMid:20123189.
http://dx.doi.org/10.1016/j.jvir.2009.01...

Another important question is standardization of exercises prescribed for CVD. Structured exercise improves calf muscle pump function in chronic venous insufficiency and the efficacy of physical conditioning has been convincingly demonstrated in patients with chronic venous disease, but none of the practice guidelines for treatment of chronic venous disease describe the aerobic or strength training used in detail.55 Khilnani NM, Grassi CJ, Kundu S, et al. Multi-society Consensus Quality Improvement Guidelines for the Treatment of Lower-extremity Superficial Venous Insufficiency with Endovenous Thermal Ablation from the Society of Interventional Radiology, Cardiovascular Interventional Radiological Society. J Vasc Interv Radiol. 2010;21(1):14-31. http://dx.doi.org/10.1016/j.jvir.2009.01.034. PMid:20123189.
http://dx.doi.org/10.1016/j.jvir.2009.01...

6 Padberg FT Jr, Johnston MV, Sisto SA. Structured exercise improves calf muscle pump function in chronic venous insufficiency: a randomized trial. J Vasc Surg. 2004;39(1):79-87. http://dx.doi.org/10.1016/j.jvs.2003.09.036. PMid:14718821.
http://dx.doi.org/10.1016/j.jvs.2003.09....
-77 Garber CE, Blissmer B, Deschenes MR, et al. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334-59. http://dx.doi.org/10.1249/MSS.0b013e318213fefb. PMid:21694556.
http://dx.doi.org/10.1249/MSS.0b013e3182...
Perhaps this is the reason Leal et al.11 Leal FJ, Couto RC, Silva TP, Tenório V. Vascular physiotherapy in treatment of chronic venous disease. J Vasc Bras. 2015;14(3):224-30. http://dx.doi.org/10.1590/1677-5449.0029.
http://dx.doi.org/10.1590/1677-5449.0029...
did not provide details of the aerobic and resistance exercises prescribed. If the objective of physical treatment is to improve calf muscle pump function, we suggest following the American College of Sports Medicine’s guidelines for exercise prescription.77 Garber CE, Blissmer B, Deschenes MR, et al. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334-59. http://dx.doi.org/10.1249/MSS.0b013e318213fefb. PMid:21694556.
http://dx.doi.org/10.1249/MSS.0b013e3182...
These recommendations may also be applied to adults with certain chronic diseases or disabilities, when appropriately evaluated and advised by a health professional.

In conclusion, the vascular physiotherapy protocol for treatment of chronic venous disease conducted by Leal et al.11 Leal FJ, Couto RC, Silva TP, Tenório V. Vascular physiotherapy in treatment of chronic venous disease. J Vasc Bras. 2015;14(3):224-30. http://dx.doi.org/10.1590/1677-5449.0029.
http://dx.doi.org/10.1590/1677-5449.0029...
achieved important results and could be enhanced with compression garments. The protocol with resistance and aerobic exercises could have been explained in greater detail in order that it could be reproduced by other health professionals.

  • Financial support: None.
  • The study was carried out at Universidade Federal do Rio Grande do Norte (UFRN), Natal, RN, Brazil.

References

  • 1
    Leal FJ, Couto RC, Silva TP, Tenório V. Vascular physiotherapy in treatment of chronic venous disease. J Vasc Bras. 2015;14(3):224-30. http://dx.doi.org/10.1590/1677-5449.0029
    » http://dx.doi.org/10.1590/1677-5449.0029
  • 2
    Lal BK. Venous ulcers of the lower extremity: definition, epidemiology, and economic and social burdens. Semin Vasc Surg. 2015;28(1):3-5. http://dx.doi.org/10.1053/j.semvascsurg.2015.05.002 PMid:26358303.
    » http://dx.doi.org/10.1053/j.semvascsurg.2015.05.002
  • 3
    Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2005;111(18):2398-409. http://dx.doi.org/10.1161/01.CIR.0000164199.72440.08 PMid:15883226.
    » http://dx.doi.org/10.1161/01.CIR.0000164199.72440.08
  • 4
    Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53(5, Suppl):2S-48S. http://dx.doi.org/10.1016/j.jvs.2011.01.079 PMid:21536172.
    » http://dx.doi.org/10.1016/j.jvs.2011.01.079
  • 5
    Khilnani NM, Grassi CJ, Kundu S, et al. Multi-society Consensus Quality Improvement Guidelines for the Treatment of Lower-extremity Superficial Venous Insufficiency with Endovenous Thermal Ablation from the Society of Interventional Radiology, Cardiovascular Interventional Radiological Society. J Vasc Interv Radiol. 2010;21(1):14-31. http://dx.doi.org/10.1016/j.jvir.2009.01.034 PMid:20123189.
    » http://dx.doi.org/10.1016/j.jvir.2009.01.034
  • 6
    Padberg FT Jr, Johnston MV, Sisto SA. Structured exercise improves calf muscle pump function in chronic venous insufficiency: a randomized trial. J Vasc Surg. 2004;39(1):79-87. http://dx.doi.org/10.1016/j.jvs.2003.09.036 PMid:14718821.
    » http://dx.doi.org/10.1016/j.jvs.2003.09.036
  • 7
    Garber CE, Blissmer B, Deschenes MR, et al. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334-59. http://dx.doi.org/10.1249/MSS.0b013e318213fefb PMid:21694556.
    » http://dx.doi.org/10.1249/MSS.0b013e318213fefb

Publication Dates

  • Publication in this collection
    Jan-Mar 2016

History

  • Received
    29 Oct 2015
  • Accepted
    27 Dec 2015
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