Varicose veins are a common condition with up to 40% of the general population having some abnormality in the superficial venous system. The onset of varicose vein has a peak incidence seen in the 4th and 5th decade of life, and there appears to be a slightly higher prevalence in women. They are important in that although the patient may seek treatment for them due to associated symptoms or for cosmetic purposes, they are a marker for underlying venous pathology in a significant proportion of patients. This can be relevant if seeking to treat more severe skin changes and ulceration, where removing superficial reflux may be beneficial to healing rates.
Chronic venous disorders (CVD) is a term generally used to describe a set of symptoms arising from the obstruction of the venous system. Chronic venous insufficiency (CVI) usually is the term used to describe definite skin changes with or without symptoms. The diversity in the clinical presentation is vast, with simple telangiectases and reticular veins with no associated symptoms, to more severe skin changes with lipodermatosclerosis and possibly ulceration. However, symptomology between disparate clinical presentations does not necessarily predict the extent of venous pathology. These symptoms can be venous or non-venous in origin, and in general are poorly correlated with objective measures of venous disease severity such as venous filling times measured with duplex ultrasound. Symptoms often are what will have brought the patient to have sought medical advice.
Impact of Varicose Veins on Sleep Quality
Sleep is a reversible state of reduced responsiveness and interaction with the environment. It is a necessary means of physiological and psychological restoration. Sleep restores the body’s energy supplies that have been depleted during the day’s activities, and all body systems are given a chance to recover. Sleep is characterized by a state of immobility, and the brain is very active. Sleep has cycles and reoccurs once every 24 hours. The sleep cycle is made up of 4 distinct stages and a period of REM (Rapid eye movement) sleep. Normally, a person will go through 4-5 sleep cycles during the night. 75% of the night is spent in non-REM sleep, and 25% in REM sleep. Non-REM sleep is a deeper and more refreshing form of sleep. The stage in sleep is characterized by slow-frequency theta waves. REM sleep occurs 90 minutes after the onset of sleep and is associated with dreaming. Sleep lasts for around 20 minutes, and the pattern is repeated. A person will spend longer in REM sleep towards the morning. It is very important to experience both stages of sleep, as a lack in any form of sleep can lead to impairment with vigilance, attention, memory, and problem-solving. Sleep is self-perpetuating and is controlled by the homeostatic and circadian processes. These ensure that sleep occurs when the person is deprived of it and to regulate the sleep occurrence during the night. Any factors that affect these processes will result in sleep disturbances, and the individual will experience a change in sleep quality.
Veins are thin-walled vessels through which the impure blood travels towards the heart. With the advancement in age and due to a sedentary lifestyle, many people develop some sort of venous problem. Venous disorders are one of the most common health problems among the population. They are usually not dangerous but can be very distressing and painful, and if left untreated, they tend to get worse with time. The venous disorders include swollen and painful legs, leg ulcers, and ache. The most common form of venous disorder is the development of varicose veins. Varicose veins are twisted and swollen veins that usually occur in the legs; the veins are close to the skin surface and resemble a cord. They can cause a throbbing, burning, or aching pain due to the discoloration of the skin. Varicose veins often cause the legs to feel heavy, tired, and restless. Sleep quality is often affected by varicose veins due to limb pain and discomfort and restless leg syndrome (RLS). Sleep is important for normal daily physical and mental function, and this essay seeks to outline the impact of varicose veins on sleep quality and the prevalence of RLS.
Disrupted Sleep Patterns
Disordered sleep is a common symptom which is significantly present in patients with varicose veins. It is characterized by a number of symptoms which include a restless quality of sleep, frequent awakening, increased movement during sleep, and pain. What is interesting is the fact that these symptoms are not self-reported by patients and they may not recognize that they are suffering from a sleep disorder. This was realized by a study which concluded that patients with varicose veins, when compared with healthy control subjects, had a significantly higher mean periodic limb movement (PLM) during sleep which caused frequent microarousals thus resulting in fragmented sleep. Furthermore, these patients displayed a higher mean PLM while awake and during various seated activities done in the study. This suggests that the symptoms of PLM and RLS are not restricted to the nighttime and can affect daytime activities. These findings have a significant impact on this particular group of patients, making them more aware that their venous disorder may be affecting their sleep and daytime functioning.
Restless Leg Syndrome (RLS)
Rls is a term used to describe two kinds of symptoms. The first is a burning, aching, or crawling discomfort in the calves, thighs, and sometimes the arms, which occurs mostly in the evening or at night. The second is an uncontrollable urge to move the legs as a result of the discomfort, and relief by movement. A patient with Rls has unpleasant feelings in the legs; the symptoms are worse during periods of inactivity and they are relieved by activity, at least for as long as the patient keeps moving. Rls is a common sensorimotor disorder with an occurrence of up to 15% in the American population. Studies have suggested that the symptoms can range from a mild annoyance to devastatingly distressing and the unpleasant leg sensations can have a severe impact on life quality and psychological wellbeing. More recent research has suggested that there is a link between Rls and varicose veins and this can often be a cause of the condition. In a study, 56% of patients that presented with Rls had venous disease. This was a much higher occurrence than in the control group. Sakkas noted that the severity of the Rls symptoms in patients with venous disease were significantly worse when compared with patients that didn’t have venous disease. He concluded that treating the venous disease could reduce the symptoms of Rls. In a more recent study, there was a comparison between patients with primary Rls and a control group. The Rls group had a much higher rate of venous insufficiency and varicose veins and it was suggested that varicose veins could be a major causative factor in patients with Rls. Patients with Rls often have Plms (periodic limb movement during sleep). This is where the patient experiences repetitive limb movements, most often the big toe or ankle, every 20-40 seconds during sleep. This can often interfere with sleep quality and Plms is more common in patients with idiopathic Rls. Yilmazer’s study suggested that varicose veins can cause Plms and it can be another causative factor of Rls.
Sleep Deprivation
An interesting study has shown that one of the major impacts of varicose veins on sleep is the increased tendency for patients to wake up during the night, due to the development of RLS. This is a condition that affects up to 10% of the population, being more prevalent in the elderly and in females. It can be a cause of considerable distress, with some patients describing the symptoms as aching, tingling or crawling sensations deep within the legs. These sensations cause an irresistible urge to move the legs to relieve the symptoms, and this is particularly marked in the evening and at night. Movement relieves the symptoms temporarily, so it is often necessary to be up and about at night, further disturbing sleep patterns. RLS has been strongly associated with chronic venous insufficiency, and a study showed the risk of RLS to be 4.965 times greater in patients with varicose veins than those without. In the treatment of varicose veins, it is important that RLS is considered, as if an underlying cause for the symptoms is removed, then there is a possibility of symptom resolution.
Management and Treatment Options
However, treatment does not stop once the procedure is complete, and this is the main difference in the management of primary and secondary VV. Let’s take a patient with superficial venous incompetence and resultant varicose veins with a view to following them through their treatment pathway. They may initially manage their symptoms conservatively by using simple techniques such as leg elevation or by taking regular paracetamol and using over-the-counter anti-inflammatory medications. This approach may well be effective to control the patient’s symptoms on a day-to-day basis and is a perfectly acceptable way to manage VV. High-impact aerobic exercise is not a recommended form of exercise as it can exacerbate leg symptoms; however, exercise in the form of walking and cycling can be beneficial and should be encouraged. If a patient’s symptoms reach a point where they are more severe or if there are skin changes present, it is likely that referral to a vascular specialist will be considered. At this point, the patient would have experienced a few years of gradually worsening symptoms and should be made aware that this is a result of a chronic disease caused by venous hypertension and not due to the varicose veins themselves.
Lifestyle Changes
Avoid wearing tight clothes, especially those that are tight around the waist, groin, and legs. Tightly fitting clothes can increase venous blood pooling. Overly tight clothes can also be partially blamed for causing varicose veins as they may restrict blood flow from the legs to the groin. Wear compression stockings to help prevent and relieve the symptoms. They steadily squeeze your legs, helping veins and leg muscles move blood more efficiently. The amount of compression varies by type and brand. You will need to be measured for them to fit properly. A trained professional usually helps people measure and fit the stockings. Drug stores sell elastic stockings that are fitted by shoe size, but these do not provide accurate compression.
Lifestyle changes: Patients can take several steps to prevent varicose veins or keep them from getting worse. Regular physical activity can help maintain proper blood flow. Exercise can also help control weight and reduce the chances of developing other chronic diseases that can impair vein health. People should avoid standing and sitting for long periods and should take a break and walk around every 30 minutes to increase venous blood flow. Avoid crossing legs when sitting. Elevating the legs and feet whenever possible above heart level will greatly help an already painful varicose vein. The patient should avoid sitting with legs dependent, as that position allows the maximum amount of blood to accumulate in the leg veins. This contributes to venous reflux, especially patients who experience Restless Leg Syndrome (RLS) should not lie down as it has been linked to a worsening of venous symptoms. Weight loss and a low-sodium high-fiber diet helps reduce the symptoms of swollen veins.
Compression Therapy
Patients with more severe varicose veins can also be treated with compression bandaging. This is done by wrapping the leg with bulky padding and an elastic bandage to apply higher levels of compression to the leg. The bandaging is to be changed regularly to maintain the appropriate pressure. Compression bandaging is used as a method of treatment on its own; however, it can also be used as a post-operative procedure for patients undergoing vein surgery. Vein surgery followed by compression therapy has shown to produce better long-term results for patients.
Compression therapy is a medication-free method prescribed by a doctor to treat venous disorders. It is known to be the most effective method for many patients and is a safe method. Medical compression stockings are used for this treatment to apply pressure to the veins and the muscles in the wall of the veins. This helps the blood flow back to the heart more effectively. Compression stockings can have preventative effects and provide good relief for mild varicose veins. They can also prevent the veins from getting worse. Studies have shown that the prescription of compression stockings is the least costly and beneficial strategy for patients with varicose veins and other chronic venous disorders, and it should be tried for 3-6 months to assess the benefit on an individual basis.
Surgical Interventions
Ligation is often performed as the initial part of the combined stripping surgery. It involves the surgical tying off of the affected vein, which can be done through small incisions under local or general anesthesia. High tie and stripping surgery can also be performed as a treatment for more severe forms of varicose veins affecting the greater saphenous vein. This procedure involves tying off the greater saphenous vein at the point where it joins the deep vein and stripping the vein downwards to the lower tie. This procedure can be technically challenging and has a risk of nerve damage.
Surgical treatments for varicose veins include stripping, ligation, and micro-phlebectomy. Stripping has been the traditional surgical treatment for varicose veins. It involves the surgical removal of the greater saphenous vein and any associated diseased veins through small incisions. Stripping is usually performed under general anesthesia and may require a hospital stay. It can be associated with significant post-operative pain and bruising. The patient may be unable to return to work for up to two weeks post-procedure and may need up to six weeks before engaging in full activity. Complications such as wound infections, deep vein thromboses, and pulmonary embolism can also occur.
Medications
Venous disease is an underappreciated cause of restless legs syndrome, a condition that can severely impair the ability to fall asleep and stay asleep. Many patients with venous RLS can attain significant relief of symptoms by allowing the leg swelling to resolve while using medications that engage the central nervous system. Dopaminergic agents and anti-epileptic medications are often a first-line medical treatment for RLS, and they work well in patients with many forms of primary or secondary RLS. Opiates or opioid-like drugs can be effective for severe RLS, but it is essential to carefully weigh their potential for dependency and abuse with the severity of the patient’s symptoms. Once venous RLS has improved, sleep quality often improves in tandem. At this point, it might be easier to convince a patient to consider intervention for his/her venous disease.
Some patients with venous disease need relief from their symptoms or skin changes. For those with venous ulcers or severe swelling, wearing compression stockings in combination with medications improves the rate of healing and decreases the likelihood of the ulcer recurring. “Phlebotropic” medications are a class of pills, not yet available in the United States, that have been shown to heal ulcers, reduce swelling, or decrease symptoms of heaviness and/or skin changes. Since these medications have not been approved by the Food and Drug Administration, patients need to be cautious and carefully scrutinize the risks and benefits before taking them.
Conclusion
In diseased states or conditions, disrupted sleep may prevent progression past NREM sleep stage II. Sleep disorders may affect, and be affected by, general medical conditions. Furthermore, they may represent primary disorders of sleep or they may reflect a disease activity or burden. Primarily, sleep disorders are divided into dyssomnias which is characterized by an inability to initiate or maintain sleep and in this case we’re interested in sleep quality as it relates to varicose veins, and parasomnias which are abnormal behavioral or physiologic events which occur in association with sleep. An example of this would be restless leg syndrome, also of interest in this paper as it relates to varicose veins.
Stage II is characterized by the presence of sleep spindles and K complexes on EEG. These complexes are thought to be protective and prevent the sleeper from awakening in response to internal and external stimuli. This stage represents 45-50% of total sleep. It is followed by Stage III, which is a period of slow wave sleep (SWS) and is characterized by low frequency, high voltage EEG activity. This stage represents about 20% of total sleep and is followed by Stage IV. These two stages make up the remaining 20-25% represented by SWS which has been considered to be the most restorative of the sleep stages.
Stage I is the transition from wakefulness to sleep and is a relatively short period of light sleep. During this stage, the EEG shows low-voltage, high frequency waves transitioning to theta waves. This is a time when many people may experience hypnic myoclonia (sudden jerking of limbs) preceded by a sensation of starting to fall. This is considered to be a part of the transition between wake and sleep.
Sleep is a crucial element in human health. Sleep has been described as being a dynamic process which is essential for physical, mental, emotional, and psychological health. Sleep is not uniform, but rather is characterized by two main states and alternating sleep stages. These stages are non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep. Healthy individuals spend 75-80% of the night in NREM sleep, occurring in 4 stages.
