Systematic review of adapted physical activity and therapeutic education of patients with chronic venous disease

BACKGROUND

Chronic venous disease (CVD), comprising impaired lower limb venous return, will lead to chronic distal venous pressure overload manifested by various clinical signs and symptoms and resulting in diminished quality of life. The CEAP (Clinical, Etiology, Anatomy, and Pathophysiology) classification of CVD distinguishes six stages (C0-C6) using clinical, etiologic, anatomic, and pathophysiologic parameters. In the present study, we analyzed the effects of adapted physical activity (APA) and patient-oriented therapeutic education (PTE) programs on the clinical signs, symptoms, and quality of life of patients with CVD.

METHODS

Our analysis, in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) recommendations, included a search of PubMed, CINAHL and LiSSa databases, using a single search equation.

RESULTS

A total of 21 studies were selected for analysis. The analysis revealed first, that patients at stage C0 to C5 had had access to an APA program. This therapy alleviated the clinical signs and symptoms and improved the patients' quality of life. The beneficial effects of APA were greater in the programs that had included aquatic activities than in the program that were exclusively dry-land programs. Second, patients at stage C6 had predominantly followed a PTE program. This therapy showed beneficial effects on the clinical signs and symptoms. However, the quality of life had rarely been assessed.

CONCLUSIONS

At present, APA and PTE programs comprise useful and complementary therapeutic options for the care of patients with CVD. Two of the studies included in our review had evaluated the effects of combining these two approaches, notably in the context of balneotherapy, and reported promising results.

THE EFFECTS OF INSPIRATORY MUSCLE TRAINING VERSUS CALF MUSCLE TRAINING ON QUALITY OF LIFE, PAIN, VENOUS FUNCTION AND ACTIVITY IN PATIENTS WITH CHRONIC VENOUS INSUFFICIENCY

OBJECTIVE

The aim of this study was to evaluate the effect of inspiratory muscle training(IMT) and calf muscle exercise training(ETC) in addition to compression therapy(CT) on quality of life, venous refilling time, disease severity, pain, edema, range of motion, muscle strength and functionality in patients with chronic venous insufficiency (CVI) compared to compression treatment alone.

METHODS

Thirty-two participants diagnosed with CVI were randomly divided into three groups. IMT in addition to compression therapy, Group 1, exercise training for the calf muscle in addition to compression therapy, Group 2, and compression therapy alone, Group 3. All the patients were assessed with the Chronic Venous Insufficiency Quality of Life Questionnaire-20, Nottingham Health Profile, photoplethysmography, venous clinical severity score, visual analog scale, intraoral pressure measurements, dynamometer, digital goniometer, 6-minute walk test and lower extremity functional scale.

RESULTS

After treatment, Group 2 improved more than groups 1 and 3 in terms of quality of life, venous refilling time, pain, edema, range of motion, muscle strength and functionality scores; Group 1 improved more than groups 2 and 3 in terms of disease severity, inspiratory and expiratory muscle strength values(p<0.05). Only physical mobility and right leg venous refilling time increased in group 3(p<0.05).

CONCLUSIONS

IMT and ETC improve venous function in both legs in patients with CVI while CT alone improves venous function only in the right leg of patients with CVI.

Exercise Training as an Adjunctive Therapy for Chronic Venous Insufficiency Patients: Evidence from Research to Practice

Chronic venous insufficiency, which is defined as a condition relevant to persistent ambulatory venous hypertension, is a common cause of venous leg ulcers. Compression therapy is commonly used to relieve ambulatory venous hypertension and heal leg ulcers. Exercise is considered as adjunctive therapy, targeting calf muscle pump function, to additionally favor the compression treatment for facilitating the healing process. Different exercise training regimens for promoting wound healing and its relevant outcomes are reviewed and discussed in this study.

The impact of exercise training on calf pump function, muscle strength, ankle range of motion, and health-related quality of life in patients with chronic venous insufficiency at different stages of severity: a systematic review

Exercise training (ET) is an important tool in the management of patients with chronic venous insufficiency (CVI). The objective of this article was to discuss the effects of ET on the calf pump, functional parameters, and quality of life of patients with mild and advanced CVI. A systematic review was conducted and eleven studies were included. In patients with mild CVI, ET was effective for improving venous reflux, muscle strength, ankle range of motion, and quality of life. In advanced CVI patients, ET increased ejection fraction, reduced residual volume fraction, and improved muscle strength and ankle range of motion, but did not change venous reflux indices or quality of life. It is concluded that ET is effective for improving calf pump function, muscle strength, and ankle range of motion in CVI. In patients with mild CVI, additional benefits were observed in quality of life.

Nursing Interventions Aimed at Persons with Venous Ulcers: an Integrative Review

Objectives: This work sought to identify and describe the theoretical foundations, components, duration, delivery mode, and results of the nursing interventions aimed at persons with venous ulcers as available in the literature. Materials and method: Integrative review between 2000 and 2018 in the Pubmed, Ovidnursing, and EBSCOhost electronic databases. Results: This review includes 16 articles. Most of the interventions were of educational nature; three were developed in the community (through the Leg Club model) and the other ones were delivered by a nursing professional, face to face. The minimum time of duration for these was eight weeks, with telephone follow up. The most-common result variables were venous ulcer healing and reduction of the wound area. Conclusions: Diversity existed in relation with the components of the interventions and the results expected. Report of the interventions must be reinforced, along with the use of nursing theories that support their design.

Evaluating the effectiveness of a self-management exercise intervention on wound healing, functional ability and health-related quality of life outcomes in adults with venous leg ulcers: a randomised controlled trial

Exercise that targets ankle joint mobility may lead to improvement in calf muscle pump function and subsequent healing. The objectives of this research were to assess the impact of an exercise intervention in addition to routine evidence-based care on the healing rates, functional ability and health-related quality of life for adults with venous leg ulcers (VLUs). This study included 63 patients with VLUs. Patients were randomised to receive either a 12-week exercise intervention with a telephone coaching component or usual care plus telephone calls at the same timepoints. The primary outcome evaluated the effectiveness of the intervention in relation to wound healing. The secondary outcomes evaluated physical activity, functional ability and health-related quality of life measures between groups at the end of the 12 weeks. A per protocol analysis complemented the effectiveness (intention-to-treat) analysis to highlight the importance of adherence to an exercise intervention. Intention-to-treat analyses for the primary outcome showed 77% of those in the intervention group healed by 12 weeks compared to 53% of those in the usual care group. Although this difference was not statistically significant due to a smaller than expected sample size, a 24% difference in healing rates could be considered clinically significant. The per protocol analysis for wound healing, however, showed that those in the intervention group who adhered to the exercise protocol 75% or more of the time were significantly more likely to heal and showed higher rates for wound healing than the control group (P = 0·01), that is, 95% of those who adhered in the intervention group healed in 12 weeks. The secondary outcomes of physical activity, functional ability and health-related quality of life were not significantly altered by the intervention. Among the secondary outcomes (physical activity, functional ability and health-related quality of life), intention-to-treat analyses did not support the effectiveness of the intervention. However, per protocol analyses revealed encouraging results with those participants who adhered more than 75% of the time (n = 19) showing significantly improved Range of Ankle Motion from the self-management exercise programme (P = 0·045). This study has shown that those participants who adhere to the exercise programme as an adjunctive treatment to standard care are more likely to heal and have better functional outcomes than those who do not adhere to the exercises in conjunction with usual care.

A home-based progressive resistance exercise programme for patients with venous leg ulcers: a feasibility study

This study aimed to assess the feasibility of a home-based exercise programme and examine the effects on the healing rates of venous leg ulcers. A 12-week randomised controlled trial was conducted investigating the effects of an exercise intervention compared to a usual care group. Participants in both groups (n = 13) had active venous ulceration and were treated in a metropolitan hospital outpatients clinic in Australia. Data were collected on recruitment from medical records, clinical assessment and questionnaires. Follow-up data on progress in healing and treatments were collected fortnightly for 12 weeks. Calf muscle pump function data were collected at baseline and 12 weeks from recruitment. Range of ankle motion data were collected at baseline, 6 and 12 weeks from recruitment. This pilot study indicated that the intervention was feasible. Clinical significance was observed in the intervention group with a 32% greater decrease in ulcer size (P = 0·34) than the usual care group, and a 10% (P = 0·74) improvement in the number of participants healed in the intervention group compared to the usual care group. Significant differences between groups over time were observed in calf muscle pump function parameters [ejection fraction (P = 0·05), residual volume fraction (P = 0·04)] and range of ankle motion (P = 0·01). This pilot study is one of the first to examine and measure clinical healing rates for participants involved in a home-based progressive resistance exercise programme. Further research is warranted with a larger multi-site study.

The prepare pilot RCT of home-based progressive resistance exercises for venous leg ulcers

OBJECTIVE

To establish the feasibility of conducting a home-based progressive resistance exercise programme to improve calf muscle pump function in community-based patients with venous leg ulcers.

METHOD

Participants were randomised to receive a 12-week progressive resistance exercise programme using heel raises in addition to compression. The control was usual care in addition to compression. Randomisation was stratified by ulcer duration and ulcer size. Air plethysmography was used to determine changes in calf muscle pump function from baseline. Changes in ulcer parameters were measured using the SilhouetteMobile device.

RESULTS

Forty participants were randomised. There were significantly greater improvements in ejection fraction of the calf muscle in the exercise group compared with the control (usual care) group (mean difference 18.5%, 95% CI 0.03 to 36.6%, p<0.05). Other parameters improved in the exercise group but the mean differences were not significant. Adherence with prescribed exercises was 81% and there was no significant difference in the numbers reporting adverse events. There were also no significant differences in ulcer healing parameters (change in area, percentage change in area, number healed at 12 weeks, time to healing).

CONCLUSION

A community-based randomised trial of progressive resistance exercise is feasible. The prescribed exercises appeared to increase ejection fraction, but the effect of exercise on ulcer healing requires further investigation.

Treatment of chronic venous insufficiency

Chronic venous insufficiency (CVI) results from venous hypertension secondary to superficial or deep venous valvular reflux. Treatment modalities are aimed at reducing venous valvular reflux, thereby inhibiting the ensuing pathologic inflammatory process. Compression therapy using pumps, bandaging, and/or graded compression stockings is the mainstay of treatment for CVI. Compression therapy has been shown to be effective in reducing venous hypertension retarding the development of inflammation and pathologic skin changes. Pharmacologic agents such as diuretics and topical steroid creams reduce swelling and pain short term but offer no long-term treatment advantage. Herbal supplements may reduce the inflammatory response to venous hypertension, but are not licensed by the US Food and Drug Administration, and vary in their efficacy, quality, and safety. However, several randomized controlled trials using the herbal horse chestnut seed extract containing aescin have shown short-term improvement in signs and symptoms of CVI. Endovascular and surgical techniques aimed at treatment of primary and secondary venous valvular reflux have been shown to improve venous hemodynamics promoting healing of venous ulcers and improving quality of life. The newer endovascular treatments of varicose veins using laser, radiofrequency ablation, and chemical foam sclerotherapy show some promise.