Evaluation of physical activity level and exercise capacity in patients with varicose veins and chronic venous insufficiency

Abstract

Objective

The clinical indication of chronic venous insufficiency (CVI) is related to functional performance and the benefits of physical activity in patients with CVI are known. Despite its importance, the literature is limited in this regard. This study aimed to determine exercise capacity and physical activity level in patients with varicose veins and CVI.

Methods

Volunteers who came to the polyclinic with leg pain complaints were enrolled in the study. Individual sociodemographic and clinical information was recorded. Individuals' pain severity was assessed by the visual analog scale (VAS) and exercise capacity was assessed by 6-minute walk test (6MWT). International Physical Activity Questionnaire (IPAQ) was used to assess the level of physical activity.

Results

The study group consisted of 51 individuals who were diagnosed with varicose veins and CVI. The control group consisted of 51 individuals without varicose veins and CVI diagnosis. In the study group, the VAS during activity was significantly higher compared to the control group. The 6MWT distance, distance %, IPAQ total score and IPAQ walking score of the control group were significantly higher in comparison with the study group (p<0.05).

Conclusions

We believe that our findings will lead the planning of interventions to increase the level of physical activity in CVI patients.

Keywords

Venous insufficiency exercise performance physical activity assessment

Introduction

Chronic venous diseases (CVD) are diseases, which develop due to venous hypertension caused by valve insufficiency and/or venous flow obstruction, and in which the venous system function is impaired. The clinical severity of CVD was determined using the Classification Clinical Manifestations, Etiological Factors, Anatomic Distribution of Disease (CEAP) classification.¹ Chronic venous insufficiency (CVI) is defined as the advanced stages (C3-C6 according to CEAP) of the existing venous disease accompanied by different pathologies such as pain, edema, skin changes, etc. and characterized by venous hypertension.²

The most important cause in the pathophysiology of CVI is venous hypertension. The main treatment is the reduction of venous reflux and congestion. One of the most effective treatment methods used to this end is compression stockings. Compression stockings prevent the accumulation of increased venous hypertension.³ The venous circulation is regulated by working the calf muscle pump with exercises such as walking. Especially for individuals working in a standing position, 2-4 minute walking exercises per 15 minutes are recommended.⁴ Moreover, the main symptoms and findings of the disease are also related to the limitation of daily life activities and the restriction of functional performance. In individuals with CVI, despite the known benefits of physical activity, it is stated that patients have activity worries due to the anxiety that their pain will aggravate.^5,6 However, there are few studies on the functional performance and physical activity level in individuals diagnosed with CVI.^7,8

This study aims to evaluate the submaximal exercise capacity and physical activity levels in patients followed up with varicose veins and CVI diagnosis.

Methods

Volunteers among the patients, diagnosed with varicose veins and CVI or followed up with the diagnosis of varicose veins and CVI after applying to the University, Medical Faculty Hospital, Cardiovascular Surgery policlinic with the leg pain complaint, participated in the study. Volunteers among the patients who were not diagnosed with varicose veins and CVI after the Doppler Ultrasonography (DUSG) evaluation constituted the control group. According to the reference study results, they had a large effect size (d = 0.67). Assuming we can achieve a lower effect size (d = 0.5), a power analysis was performed before the study. Accordingly, when at least 102 participants (at least 51 study group and 51 control group) were included in the study, that would result in 80% power with %95 confidence level (%5 type 1 error rate).

The inclusion criteria for cases in the study group are being under 85 years of age, and not having active or healed ulcer wounds (CEAP stage 5, 6), being in C2 according to the CEAP and CVI. The inclusion criteria for the cases in the control group are being CEAP 0, being under 85 years of age, and having a leg pain complaint for at least three months. The exclusion criteria are having an orthopedic problem (amputation, arthrosis, etc.), which is an obstacle to the walking of individuals, being diagnosed with any heart disease (heart failure, etc.), pulmonary disease (COPD, asthma, etc.), not being oriented or cooperated, and being pregnant.

The approval for the study was received from the Clinical Research Ethics Committee of the University, (Decision No: 06/11). An informed consent form was signed by the individuals participating in the study.

The age, sex, height, and weight of the individuals were recorded. The body mass index (BMI) was calculated using the formula of body weight/height² (kg/m²). The individuals were grouped as slim (<18.5 kg/m²), normal (18.5-24.9 kg/m²), overweight (25-29.9 kg/m²), and obese (30-39.9 kg/m²). The socio-demographic characteristics and clinical information of the individuals were recorded. Other symptoms that might be related to CVI (cramp, heaviness, tension, sensitivity, edema) were questioned.

The lifestyle habits, such as whether individuals smoked or exercised, if they exercised, what type of exercise they performed and how many days and minutes (min) they exercised, were questioned.

Pain assessment

Pain intensity was measured by the visual analogue scale (VAS). The VAS is a simple, effective, repeatable, and easy to use pain intensity measurement method. The VAS is frequently preferred in situations when pain intensity should be measured quickly in the clinic. To obtain reliable data using the VAS, the “0” and “10” points of the VAS are explained with short standardized expressions.⁹ The individual was asked to mark pain intensity on a line 10 cm in length (“0” means no pain, “10” means unbearable pain). The localization of the pain in individuals and the cases increasing and decreasing pain were questioned and recorded.

The six-minute walking test

The 6-minute walking test (6MWT) was performed to assess the submaximal exercise capacity of individuals. The 6MWT was applied to all patients by the same physiotherapist following the standard instruction of the test. Individuals were made to rest for at least 10 minutes before the test. Before starting the test, individuals were told that they could slow down or stop and rest when they felt discomfort such as shortness of breath, chest pain, dizziness, leg pain, leg cramps, etc. during the test. It was stated that the period during which they could stop and rest was included in the test. Patients were asked to walk as fast as they could without running during the 6MWT.¹⁰

The heart rate was measured using a Polar heart rate sensor (Polar FT1 Training Computer Cardiofrequencymeter/Polar Electro Oy, Finland) before and during the test. The level of dyspnea and fatigue at the beginning and end of the test was assessed using the modified borg scale and recorded. The modified borg scale is a scale that assesses fatigue and shortness of breath from 0 to 10.¹¹ The total walking distance was recorded after the 6MWT. The 6MWT distance is interpreted according to normal values for healthy adult population according to age, sex, height, and weight. In this study, the reference equality of Troosters et al. was used.¹² The estimated 6MWT distance= 218 + [(5.14 × height – (5.32 × age)] – [(1.80 × weight) + (51.31 ×sex)] (1-male, 0-female).

Table 1.

Socio-demographic characteristics of the individuals.

		Study group	Control group	p
Gender	Male n (%)	13 (25.49%)	17 (33.33%)	0.385 (chi-square = 0.756)
Gender	Female n (%)	38 (74.51%)	34 (66.67%)	0.385 (chi-square = 0.756)
Age (year)	A.M± Std.Err.	46.76 ± 1.74	48.94 ± 1.97	0.411 (t=−0.826)
Age (year)	Med (min–max)	49 (23–76)	52 (21–70)	0.411 (t=−0.826)
BMI (kg/m²)	A.M± Std.Err.	30.68 ± 0.9	27.39 ± 0.64	0.004* (t = 2.969)
BMI (kg/m²)	Med (min–max)	29.69 (18.75 –51.95)	26.26 (18.38 – 41.62)	0.004* (t = 2.969)
Exercise	Yes n (%)	5 (9.8%)	6 (11.76%)	0.75 (chi-square = 0.102)
Exercise	No n (%)	46 (90.2%)	45 (88.24%)	0.75 (chi-square = 0.102)
Number of days**	A.M± Std.Err.	3.4 ± 0.68	5.33 ± 0.56	0.126 (z=−1.694)
	Med (min–max)	3 (2–5)	5 (4–7)	0.126 (z=−1.694)
Number of minutes**	A.M± Std.Err.	30 ± 2.74	30.83 ± 3	0.931 (z=−0.196)
	Med (min–max)	30 (25–40)	30 (25–45)	0.931 (z=−0.196)
Smoking status	Yes n (%)	13 (25.49%)	10 (19.61%)	0.773 (chi-square = 0.515)
	No n (%)	30 (58.82%)	32 (62.75%)
	Quitted n (%)	8 (15.69%)	9 (17.65%)
Smoking exposure (packagexyear)**	A.M± Std.Err.	16 ± 2.73	21.18 ± 3.01	0.196 (z=−1.302)
	Med (min–max)	15 (1.25–40)	20 (2.5–60)	0.196 (z=−1.302)
Period of quitting (years)**	A.M± Std.Err.	9 ± 2.37	8.84 ± 2.63	0.815 (z=−0.29)
	Med (min–max)	8 (1–18)	6 (0.1–20)	0.815 (z=−0.29)

*p < 0.05 is the statistically significant difference; ** examinations were performed as n = 5 in the study group and n = 6 in the control group; z: Mann-Whitney U test value; chi-square: Chi-square test value; A.M: Arithmetic Mean; Std.Err: Standard Error; med: Median; min-max: Minimum and maximum values; ** examinations were performed as n = 21 in the study group and n = 19 in the control group for smoking exposure (packagexyear); and as n = 8 in the study group and n = 19 in the control group for the period of quitting (years).

The 6MWT percentage (%) distance was obtained by proportioning the distance that the individuals walked to the expected normal values and calculating it as a percentage.¹²

Assessment of the physical activity level

The Turkish version of the International Physical Activity Questionnaire (IPAQ) Short Form was used to assess the physical activity levels of individuals.^13,14 MET (metabolic equivalent), multiples of the resting metabolic rate, is used to determine the energy required for performing activities. To determine the physical activity levels, a score of MET-minute is obtained by multiplying the MET value, day, and minute. The walking period is multiplied by 3.3 MET for the walking score. The 4 MET value is taken for moderate-severity physical activity, and 8 MET is taken for severe physical activity.

The physical activity levels are determined in 3 categories. They are categorized as inactive individuals (<600 MET-min/wk), individuals with the low physical activity level (600-3000 MET-min/wk), and individuals with the sufficient physical activity level (>3000 MET-min/wk). The IPAQ sitting score is an additional indicator and is not included in the physical activity scoring.¹³ In this study, a 7-question short form containing the “last seven days” of the questionnaire was used.

Statistical analysis

The data were analyzed using the SPSS package program. Continuous variables were presented as a mean±standard error, median (minimum and maximum values), and categorical variables were presented as number (n) and percentage (%). The significance test of the difference between two means was used to compare the study and control group differences when parametric test assumptions were provided, and the Mann-Whitney U test was used to compare the study and control group differences when parametric test assumptions were not provided. The difference between the categorical variables was examined by the chi-square test. Furthermore, there was a significant difference between the groups when the BMI levels of the study and control groups were compared. Covariance analysis was used in the study due to this difference. In all analyses, p<0.05 was considered statistically significant.

Results

Fifty-one individuals, who were diagnosed with C2 and CVI (excluding C5-C6) as a result of the assessment performed with DUSG and physical examination by a cardiovascular surgeon, constituted the study group, and 51 individuals, who were not diagnosed with CVI and were followed up, constituted the control group.

The socio-demographic characteristics of the individuals are presented in Table 1. The mean BMI of the individuals in the study group was 30.68 ± 0.9 kg/m², and the mean BMI of the individuals in the control group was 27.39 ± 0.64 kg/m². Of the individuals in the study group, 13.7% (7 individuals) were normal weight, 41.2% (21 individuals) were overweight, and 45.1% (23 individuals) were obese. Of the individuals in the control group, 2% (1 individual) were slim, 21.6% (11 individuals) were normal weight, 45.1% (23 individuals) were overweight, and 31.4% (16 individuals) were obese. While there was no statistically significant difference between the study and control groups in terms of age and sex (p > 0.05), there was a significant difference between the two groups in terms of BMI (p<0.05). The right extremities of all the individuals participating in the study were dominant. There was no significant difference between the two groups regarding exercise habit and smoking habit (p>0.05).

The symptom distribution is presented in Table 2. All of the patients experienced pain. Cramp (78.43%), feeling of heaviness (74.51%), and tension (58.82%) were observed at a significant level among the other symptoms. The clinical findings and CEAP classification of CVD in the individuals in the study group are summarized in Table 3. It was determined that the superficial venous system was affected in 92.16% of the individuals in the study group, and the highest influence rate was in the large saphenous vein (68.63%). It was revealed that both legs were affected in 56.86% of the patients. According to the CEAP classification, 54.90% of the patients were C3 (edema).

Table 2.

The symptom distribution of the individuals in the study group.

		Number (n)	Percentage (%)
Pain	Yes	51	100
Cramp	Yes	40	78.43
	No	11	21.57
Feeling of heaviness	Yes	38	74.51
	No	13	25.49
Tension	Yes	38	74.51
	No	13	25.49
Skin sensitivity	Yes	15	29.41
	No	36	70.59
Edema	Yes	30	58.82
	No	21	41.18

Table 3.

Clinical findings and CEAP classification of the individuals in the study group.

		Number	Percentage (%)
Affected system	Superficial	47	92.16
	Deep	4	7.84
Affected vein	Vena saphena magna (VSM) (large saphenous vein)	35	68.63
	Vena saphena parva (VSP) (small saphenous vein)	2	3.92
	Saphenofemoral junction (SFJ)	9	17.65
	Perforator vein	2	3.92
	VSM and VSP	1	1.96
	Perforator and VSM	2	3.92
Affected leg	Right	9	17.65
	Left	13	25.49
	Bilateral	29	56.86
CEAP classification	C2 (varicose veins)	21	41.18
	C3 (edema)	28	54.90
	C4 (skin or subcutaneous changes)	2	3.92

The two groups were similar in terms of resting and night-time VAS values (p>0.05). The VAS value during the activity was significantly higher in the study group (6.58 ± 0.37 cm) than the control group (4.49 ± 0.37 cm, p<0.05, Table 4).

Table 4.

Comparison of the 6-minute walking test values and the pain intensity of the study and control groups.

		Study group		Control group
		A.M± Std.Err.	95% Confidence Intervals	A.M± Std.Err.	95% Confidence Intervals	p
Heart rate (beat/min)	Start	85.84 ± 1.66	82.55–89.13	80.12 ± 1.66	76.83–83.41	0.019* (F = 5.701)
	Finish	104.93 ± 1.97	101.02–108.85	104.48 ± 1.97	100.56 - 108.39	0.873 (F = 0.026)
	Recovery	91.68 ± 1.68	88.34–95.02	90.34 ± 1.68	87–93.68	0.583 (F = 0.303)
Dyspnea (M. Borg)	Start	0.14 ± 0.05	0.03–0.25	0.11 ± 0.05	0–0.21	0.673 (F = 0.179)
	Finish	0.62 ± 0.13	0.36–0.88	0.61 ± 0.13	0.35–0.87	0.952 (F = 0.004)
	Recovery	0.23 ± 0.08	0.07–0.39	0.27 ± 0.08	0.11–0.43	0.79 (F = 0.071)
Fatigue (M. Borg)	Start	0.74 ± 0.17	0.42–1.07	0.7 ± 0.17	0.37–1.02	0.842 (F = 0.04)
	Finish	1.54 ± 0.22	1.11–1.97	1.47 ± 0.22	1.04–1.9	0.811 (F = 0.058)
	Recovery	0.96 ± 0.17	0.62–1.3	0.86 ± 0.17	0.52–1.2	0.692 (F = 0.158)
Distance (m)		386.78 ± 12.34	362.29–411.26	500.88 ± 12.34	476.39 - 525.36	0.0001* (F = 41.015)
Distance %		57.66 ± 1.97	53.76–61.56	78.73 ± 1.97	74.83–82.63	0.0001* (F = 55.178)
Resting VAS (cm)		2.11 ± 0.4	1.32–2.9	1.79 ± 0.4	1–2.59	0.582 (F = 0.305)
Activity VAS (cm)		6.58 ± 0.37	5.84–7.32	4.49 ± 0.37	3.75–5.23	0.0001* (F = 14.976)
Night-time VAS (cm)		2.69 ± 0.51	1.68–3.69	2.22 ± 0.51	1.22–3.23	0.525 (F = 0.406)

*p < 0.05: bmi = statistically significant difference according to the Covariance analysis results corrected according to 29.0363 value; F: Covariance Analysis test value; A.M: Arithmetic Mean; Std.Err: Standard Error.

The patients in both groups were provided with the opportunity to take a break during the 6MWT when needed. All the patients in the control group completed the test without a break. However, only 4 of the patients in the study group felt the need to take a break and took a break only once during the test. Other patients with varicose veins or CVI felt no need to take any break and completed the test without any breaks. The comparison of the results of the 6MWT between the study and control groups is presented in Table 4. The heart rate, dyspnea, and fatigue parameters of the recovery period before, during, and after the test were similar, except for the heart rate before the test (p>0.05). The pre-test heart rate (85.84 ± 1.66 beat/min) was higher in the study group than in the control group (80.12 ± 1.66 beat/min, p<0.05). The 6MWT distance and distance % values of the control group (500.88 ± 12.34 m, 78.73 ± 1.97%) were significantly higher compared to the study group (386.78 ± 12.34 m, 57.66 ± 1.97%, p<0.05).

The comparison of the IPAQ-short form scores between the study and control groups is presented in Table 5. There was a statistically significant difference between the two groups in terms of the IPAQ total score and IPAQ walking score (p<0.05). The study group scores (1026.43 ± 302.04; 757.05 ± 90.96 MET-min/wk) were significantly lower when compared to the control group (1966.1 ± 302.04; 1317.11 ± 90.96 MET-min/wk).

Table 5.

Comparison of the physical activity scores and the physical activity levels of the study and control groups.

	Study group		Control group
MET-min/wk	A.M± Std.Err.	95% Confidence Intervals	A.M± Std.Err.	95% Confidence Intervals	p
IPAQ total score	1026.43 ± 302.04	427.12–1625.74	1966.1 ± 302.04	1366.79–2565.41	0.034* (F = 4.643)
IPAQ walking score	757.05 ± 90.96	576.56–937.54	1317.11 ± 90.96	1136.61–1497.6	0.0001* (F = 18.186)
IPAQ medium-severity score	183.45 ± 48.98	86.25–280.65	205.18 ± 48.98	107.98–302.37	0.759 (F = 0.094)
IPAQ severe score	84.92 ± 267.52	−445.9–615.73	438.22 ± 267.52	−92.59–969.04	0.363 (F = 0.837)
IPAQ sitting period (min)	264.87 ± 15.41	234.3–295.4	248.66 ± 15.41	218.09–279.23	0.468 (F = 0.531)
Physical Activity Level	Study	Control	Total	p
Inactive	15 (29.41%)	6 (11.76%)	21 (20.59%)	0.076 (chi-square = 5.162)
Low	33 (64.71%)	40 (78.43%)	73 (71.57%)
Sufficient	3 (5.88%)	5 (9.8%)	8 (7.84%)
Total	51 (100%)	51 (100%)	102 (100%)

Of the individuals in the study group, 29.4% were inactive. Individuals with a low physical activity level constituted 64.7%, and individuals with a sufficient physical activity level constituted 5.9%. Of the individuals in the control group, 11.8% were inactive. Individuals with a low physical activity level constituted 78.4%, and individuals with a sufficient physical activity level constituted 9.8%. The comparison of the physical activity levels between the two groups is presented in Table 5. There was no significant difference between the two groups in terms of the physical activity levels (p>0.05).

The comparison of the physical activity scores and 6MWT distance and distance % values of the CEAP C2 (varicose veins) and C3 (edema) classes of the individuals in the study group is presented in Table 6. There was a statistically significant difference between the two groups in terms of the 6MWT distance and distance % values (p<0.05). The 6MWT % distance values of the C2 (varicose veins) class were significantly higher (63.8 ± 2.84; 55.69 ± 2.12%).

Table 6.

Comparison of the physical activity and 6MWT% distance values of the CEAP C2 (varicose veins) and C3 (edema) classes.

MET-min/wk		A.M ± Std.Err.	med (min–max)	P
IPAQ sitting period (min)	2.00 (n = 21)	248.57 ± 20.19	270 (30–420)	0.524 (z=−0.637)
IPAQ sitting period (min)	3.00 (n = 28)	278.57 ± 19.75	240 (90–480)	0.524 (z=−0.637)
IPAQ walking score	2.00 (n = 21)	626.93 ± 72.4	577.5 (198–1386)	0.101 (z=−1.212)
IPAQ walking score	3.00 (n = 28)	851.32 ± 100.2	693 (132–2079)	0.101 (z=−1.212)
IPAQ medium-severity score	2.00 (n = 21)	168.57 ± 54.15	0 (0–840)	0.225 (z=−0.72)
IPAQ medium-severity score	3.00 (n = 28)	257.14 ± 80.32	30 (0–1960)	0.225 (z=−0.72)
IPAQ severe score	2.00 (n = 21)	85.71 ± 51.66	0 (0–960)	0.471 (z=−0.797)
IPAQ severe score	3.00 (n = 28)	74.29 ± 54.42	0 (0–1440)	0.471 (z=−0.797)
IPAQ total score	2.00 (n = 21)	881.21 ± 100.82	886.5 (291–2226)	0.426 (z=−1.639)
IPAQ total score	3.00 (n = 28)	1184.18 ± 124.66	1092 (346.5–2826)	0.426 (z=−1.639)
6MWT distance (m)	2.00 (n = 21)	419.85 ± 96.51	420 (180–598.5)	0.01* (z=−2.577)
6MWT distance (m)	3.00 (n = 28)	357.81 ± 72.5	386.15 (148–450)	0.01* (z=−2.577)
6MWT % distance (%)	2.00 (n = 21)	63.8 ± 2.84	64.19 (28.17–93.26)	0.015* (z=−2.443)
6MWT % distance (%)	3.00 (n = 28)	55.69 ± 2.12	57.09 (18.94–72.86)	0.015* (z=−2.443)

*p < 0.05 statistically significant difference; z: Mann-Whitney U test value; t: The significance test value of the difference between two means; A.M: Arithmetic mean; Std.Err: Standard error; med: median; min-max: The minimum and maximum values.

Discussion

In this study, the exercise capacity and physical activity level were evaluated in varicose veins and CVI patients without a venous ulcer. Although they were not in the advanced stage of CVI, it was noted that the exercise capacity and physical activity level were lower in CVI patients.

CVI is not a disease that can be treated completely, either medically or surgically.¹⁵ The prevention of the complications it may cause and patient comfort are the main goals. In veins with reflux, vascular permeability is deteriorated with the increased stasis and pressure in the veins. First, the amorphous elements become extravasated. Then, the erythrocytes become extravasated and degraded, and intense iron accumulation occurs in the tissue. This further deteriorates the circulation and reduces tissue regeneration. Regardless of which surgical method is preferred, almost all surgical options are just removing the extremely enlarged venous structures from the venous circulation system. In medical treatment, it is aimed to try to increase the venous tone. Correcting the main causing venous reflux is usually not possible with medications. However, compression socks can prevent reflux, which is caused by veins that are extremely enlarged and have thus caused valve insufficiency. After the prevention of reflux, the calf muscle pump is worked with light exercises such as walking, and the venous circulation is increased. Thus, both edema and all other symptoms, especially cramps, significantly regress and the progression of the disease is stopped.¹⁶ The importance of physical activity in patients with CVI is emphasized.⁶ However, despite the importance of the subject, studies evaluating the physical activity level, physical fitness, and exercise capacity in venous insufficiency patients are not sufficient. Among previous studies, there are studies in which only calf muscle pumping functions and walking parameters were reviewed in CVI patients.^17–19

The patient group diagnosed with CVD (C2-C3-C4) and the control group did not have exercise habits. When assessed more in detail in terms of the physical activity, it was indicated that both groups were inactive and minimally active according to the IPAQ classification. The pain complaint in both groups was thought to be caused by physical inactivity. In this study, when the groups were compared according to pain intensity, it was determined that the pain felt by the study group, which included varicose veins and CVI patients, during the activity was more severe. The only significant difference between the two groups in terms of the IPAQ results was the fact that the walking score of varicose veins and CVI patients was significantly lower. Previous studies indicate that the fear of activity or concern about increased pain may play a role reducing physical activity levels in CVI patients.^6,20 In parallel with this view, it was concluded that the more severe calf pain in the study group during the activity might have reduced the walking activity.

When the 6MWT results assessing the exercise capacity of two groups were interpreted, the fact that the study group experienced more severe fatigue and dyspnea although they walked a shorter distance was an indicator of reduced exercise capacities in patients with varicose veins or CVI. It was desired to discuss the results of this study concerning the literature. However, studies evaluating the exercise capacity in CVI patients were not found.

It is observed in some studies that the gait of patients diagnosed with CVI and venous ulcer was assessed.^21,22 Van-Uden et al. reported that the support surface increased while the gait speed decreased in individuals diagnosed with CVI²¹, and Pieper et al. reported that the balance decreased in patients with CVI and that the decrease in balance adversely affected the gait.²² It was considered that these studies supported the results of the present study.

On the other hand, there are several studies in the literature assessing the physical fitness and functional mobility in patients with a venous ulcer.^22,23 These studies report that the physical performance of venous ulcer patients is lower than that of CVI patients without an ulcer.²² Although this study did not include CVI patients with a venous ulcer, it was observed that the exercise capacity was affected more negatively as the severity of venous insufficiency increased. According to the CEAP classification, walking distances were less in the 6MWT in patients in the C3 class than those in the C2 class. In fact, these results reveal the need for patients to be directed to a regular physical activity after being diagnosed with CVD. As the degree of insufficiency increases, a decrease in exercise capacity is expected.

The guidelines for the management of venous ulcers and CVI include lifestyle modifications that need to be addressed, such as exercise, nutrition, and smoking.²⁴ Obesity and overweight have been shown to contribute to the pathophysiology of CVI.²⁵ As is known, exercise training is routinely recommended for all cardiovascular diseases. In a review study, it is shown that controlled walking exercises in CVI patients at a mild level develop skin microvascular functions in the lower extremity. Therefore, it is emphasized that exercise-related studies are needed in patients with CVI and venous ulcers.²⁴ Likewise, in an evidence-based review study, it is indicated that there are insufficient data on the assessment of the effects of exercise training in CVI patients.²⁶ As can be seen, there is a growing interest in the effectiveness of exercising in CVI patients. However, the first step before determining the appropriate exercise training approaches in these patients should be the assessment of the exercise capacities of patients.

In conclusion, this study is significant because it is the first to assess the exercise capacity and physical activity levels in varicose veins and CVI. We believe that the findings of this study indicating that the exercise capacity decreases in patients with varicose veins and CVI will guide the planning of interventions to assess the exercise capacity and physical activity level in varicose veins and CVI patients and, at the same time, to increase the physical activity level in patients with varicose veins and CVI, in subsequent studies.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

The ethics committee of Kırıkkale University, Clinical Research Ethics Committee approved this study (Decision No: 06/11).

Guarantor

E Sakızlı Erdal

Contributorship

All authors reviewed and edited the manuscript and approved the final version of the manuscript.

Acknowledgements

We would like to thank the Kırıkkale Unıversity Department of Cardiovasculary Surgery and Kırıkkale Unıversity Department of Physiotherapy and Rehabilitation, for their clinic assistance and guidance in this study.

ORCID iD

Elif Sakızlı Erdal

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