Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 53  |  Issue : 2  |  Page : 134-140

Yoga and its adjuvant therapies for the management of varicose vein disease: A narrative review


1 Department Yoga and Life Sciences, Swami Vivekananda Yoga Anusandhan Samsthan, Bengaluru, Karnataka, India
2 Department of Yoga, Central University of Rajasthan, Ajmer, Rajasthan, India

Date of Submission29-Sep-2021
Date of Acceptance29-Oct-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Sanjib Kumar Patra
Central University of Rajasthan, NH-8, Bandar Sindri, Dist-Ajmer - 305 817, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ym.ym_108_21

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  Abstract 


Varicose veins (VVs) are twisted and dilated veins, mostly located in the lower limbs. The particular condition is mostly neglected due to lack of awareness about the issue, lack of symptoms, or late appearance of symptoms. The current review summarizes the overview of VV and available treatment options (conventional as well as nonconventional such as Ayurveda, exercise, and Yoga) for VV. VVs can range from uncomplicated asymptomatic visible small veins to symptomatic complicated varicose eczema and varicose ulcers. We identified 200 papers on VV between 2000 and 2021, out of which 40 were selected for particular review. Article search was done through Medline, Google Scholar, PubMed, psycINFO, and EMBASE using the keywords “varicose veins” and “surgery,” “treatment,” “conservative methods,” “Ayurveda,” “exercise,” and “Yoga.” The randomized and nonrandomized control, self as control studies, narrative reviews, systematic reviews, as well as case studies are included. The review focuses on the importance of nonconventional alternative form of therapies, specially Ayurveda, exercise, and Yoga, for the management of VV. There are a large number of studies done on VV, but a negligible number of studies are available to prove the effectiveness of Yoga on the particular condition. A lot of research trials on urgent basis are needed to prove the efficacy of Yoga in VV disease.

Keywords: Adjuvant therapies, Ayurveda, exercise, varicose veins, Yoga


How to cite this article:
Chauhan S, Patra SK. Yoga and its adjuvant therapies for the management of varicose vein disease: A narrative review. Yoga Mimamsa 2021;53:134-40

How to cite this URL:
Chauhan S, Patra SK. Yoga and its adjuvant therapies for the management of varicose vein disease: A narrative review. Yoga Mimamsa [serial online] 2021 [cited 2022 Jul 3];53:134-40. Available from: https://www.ym-kdham.in/text.asp?2021/53/2/134/333348




  Introduction Top


Varicose veins (VVs) are the twisted, dilated, elongated, and tortuous superficial veins with balloon-like bulges in between (Pedrycz & Budzyńska, 2016) mostly located on the lower extremities (Raetz, Wilson & Collins, 2019; Lim, Gohel, Shepherd, Paleolog & Davies, 2011) and belong to chronic venous disorder (Fiebig et al., 2010). The term “varicose” has been coined from the Latin root varix, which means “twisted” and can be observed clinically by swollen subcutaneous veins appearing as cords and bulging, especially in the legs (Somers & Knaapen, 2006).

VV is the important cause of morbidity and disability in the today's world, which shows negative impact on quality of life of individuals (Bootun, Onida, Lane & Davies, 2016). The incidence of VV has been shown to vary among populations between 10% and 60% (adult population) as shown by various studies (Selçuk Kapısız, Uzun Kulaoğlu, Fen & Kapısız, 2014). VV is affecting about 10–20% the Western population but around 5% in India (Mishra, Ali et al., 2016). The reported incidence of VVs in the Indian population seems to be low as compared to western population due to either no reporting or late reporting of condition, when complications such as pain, swelling, and ulceration occur (Kiran Shankar, 2017). Among Indians, high prevalence was found in North Indian population affecting approximately half of females and one-third of males (Agarwal et al., 2016). A cross-sectional study in Udaipur has shown higher incidence of VV among nurses, especially females as compared to male counterparts (Mishra, Solanki & Mishra, 2015).

According to Basle criteria, VVs are “dilated and palpable subcutaneous veins mostly larger than 4 mm in diameter” (Beebe-Dimmer, Pfeifer, Engle & Schottenfeld, 2005).

Heredity (Shadrina et al., 2018) or family history of venous disease; female gender; old age; chronically increased intra-abdominal pressure due to conditions such as obesity, pregnancy, parity more than three (Jukkola et al., 2006), history of leg injury (Lacroix, Aboyans, Preux, Houles & Laskar, 2003), chronic constipation, or a tumor; as well as prolonged standing or sitting for longer hours (Lacroix et al., 2003), alcohol intake and smoking (Ahti, Mäkivaara, Luukkaala, Hakama & Laurikka, 2010), use of oral contraceptive drugs, hormone replacement therapy, tobacco intake, low-fiber diet, hot baths (Pedrycz & Budzyńska, 2016) are the contributing risk factors for VVs (Raetz et al., 2019). Weight lifting, wearing tight dresses, and high heels may disturb heel to toe movement significantly which reduces calf muscle activity and contribute to VV development. The causes of VV are summarized in [Figure 1].
Figure 1: Summarizing causes of Varicose veins

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VVs can be classified in two types; primary VVs (which has intact or normal deep veins) and secondary VVs which occur in various locations, e.g., on the great saphenous vein, on accessory posterior and anterior saphenous vein, or on small saphenous vein (Pedrycz & Budzyńska, 2016).

Initially, VVs may not cause any pain. Feeling of discomfort due to tiredness, heaviness of legs (Raetz et al., 2019; Pedrycz & Budzyńska, 2016; Korzhyk, 2016), and night cramps are usually the first symptoms in many cases. The consequent symptoms may include swelling or edema at the lateral and medial side of ankle as well as the dorsum of the foot; dull or burning pain, itching (Raetz et al., 2019; Pedrycz & Budzyńska, 2016; Korzhyk, 2016), and pins and needles like sensation (paresthesia). The symptoms worsen after standing for prolonged period of time (Raetz et al., 2019). Skin discoloration and hardenings, eczema, and swelling over the shin area may continue even after a night rest (Pedrycz & Budzyńska, 2016; Korzhyk, 2016).

VV can be associated with few complications which may be the sign of more serious vascular insufficiency, which may precipitate in the form of changes such as skin pigmentation, eczema, skin infections, venous ulceration, superficial thrombophlebitis, loss of subcutaneous tissue, or sometimes external hemorrhage caused due to rupture of VV (Racette & Sauvageau, 2005; Raetz et al., 2019).

Despite lot of researches in particular field, the exact precise underlying mechanism behind the progress and development of this particular issue remains uncertain. The past initial theories pointed toward purely mechanical nature of the disease, but latest theories point toward complex changes in molecular structures, leading to histologic changes in vessel wall as well as extracellular matrix (ECM) (Oklu et al., 2021).

Lower limb venous system can be divided into three components, viz., deep, superficial, and perforating veins, which work together; the dysfunction of single compartment leads to dysfunction of others, resulting in development of VV disease (Somers & Knaapen, 2006). One of the hypothesis states that VV can develop due to the combination of alteration in venous tone and defects in underlying connective tissues, which is compatible with the studies which suggest that the impairment in regulation of ECM, degradation, and few depositions may have an important role in pathogenesis of varicosities. Several constituents of ECM such as collagens and elastins are modified with decrease in elastin/collagen ratio. Decreased smooth muscle cells and total protein content are also evident. Fragmentation of muscle layers further compromise effectiveness of contractions. Overproduction of type I collagen accompanied with reduced production of type III collagens causes tissue rigidity. Activated leukocytes have been evident in VV which results in release of free radical, protease activation, and further ECM degradation. To sum up, the changes in connective tissue proteins as well as exaggerated proteolytic enzyme activity appears to play a main role in pathophysiology of VV. Abnormalities developed in vein wall architecture may precede valvular incompetence, resulting into varicosity (Oklu et al., 2012).

Mostly, the valvular dysfunction is caused due to reduction in elasticity in vein wall together with failure of valve leaflets to close properly. Altered shear stress on venous endothelial cells caused due to reversed or turbulent blood flow as well as inflammation proves to be an important etiological factor contributing for venous disease (Raetz et al., 2019). Treatment options available for VV can be conventional, which can be interventional or conservative (Raetz et al., 2019). Interventional method may be accompanied with few adverse effects (Goldman, 2002; Piazza, 2014). Ayurveda (Wickramasingha & Ediriweera, 2018), exercise (Helal et al., 2016) as well as Yogic therapies are few remedies which can prove its effectiveness without causing adverse effects in VV condition. Yoga has been used over decades for improving VV condition, but there is lack of studies available proving its efficacy in particular condition. There is urgent need to have clinical studies proving effectiveness of Yoga in VV condition.


  Methodology Top


For the particular review, we identified 200 papers on VV between 2000 and 2021, out of which 40 were selected depending on the quality, content, and originality of the articles. The comprehensive search was made through search engines; Medline, Google Scholar, PubMed, psycINFO, and EMBASE using the keywords “varicose veins” and “surgery,” “treatment,” “conservative methods,” “Ayurveda,” “exercise,” and “Yoga.” The randomized and nonrandomized control, self as control studies, narrative reviews, systematic reviews as well as case studies are included.


  Treatment Modalities Used to Manage Varicose Veins Top


Medical treatment (conventional)

The selection of therapies for VVs depends specifically on symptoms, location, severity of disease, and causative factor. The majority of patients who suffer from VV require a multidimensional approach (Piazza, 2014). There has been a tremendous change in treatment recommendations in the last 10 years in symptomatic VV conditions mostly due to lack of evidence which supports usage of compression stockings (CS) and increase in endovascular techniques that are minimally invasive. Broadly, treatment options for VVs can be divided into conservative management and interventional methods (Raetz et al., 2019).

Conservative management

The management options through conservative methods include external compression, changes in lifestyle such as avoiding standing and straining for longer durations, avoiding tight clothes, modifying cardiovascular risk factors, weight loss, use of phlebotonics, leg elevation, and measures to reduce peripheral edema (Raetz et al., 2019).

Either individually or accompanied with interventional therapies, lifestyle modifications are verified to provide complete and long-lasting treatment response as far as possible. As VVs are associated with obesity, weight loss proves to be important factor in reducing disease progression as well as preventing recurrence. Physical activities such as walking and foot flexions on regular basis may improve calf muscle pump function. Feet elevation to heart level or more, for 30 min 4 times a day accompanying with avoiding prolonged standing and sitting, decompresses veins of lower extremity and improves symptoms. Cessation of smoking should be encouraged in VV individuals. CS was frequently prescribed as first line of treatment in leg discomfort and edema. CS reduces venous reflux as well as venous hypertension, thereby improving venous hemodynamics (Piazza, 2014). The consensus document 2018 indicates that medical compression stockings (MCS) is now firmly established as a treatment modality for many venous and lymphatic conditions. Some local conditions in which MCS is contraindicated are advanced peripheral neuropathy, fragile and thin skin, dermatitis, and allergy to the particular fabric used in MCS. One of the problems with MCS is that the standard size of stockings cannot be made and it needs to customize according to the individual due to difference in leg sizes and shapes (Rabe et al., 2018).

Interventional methods - Thermal ablation

Thermal ablation is used to destroy damaged veins by utilizing heat energy. Thermal ablation generally includes two methods, i.e., endovenous laser ablation (utilizing laser energy) as well as radiofrequency ablation (utilizing radiofrequencies). Thermal energy destroys endothelial as well as mural collagens leading to coagulation and thrombus formation, which results in closure of affected vein; further, blood flow is redirected to functional veins. The procedures are ultrasound guided and done under local anesthesia. External laser ablation is generally applied for telangiectasias or small varicose veins, whereas endovenous thermal ablation is employed for larger vessels which includes great saphenous vein (Goodyear & Nyamekye, 2015; Raetz et al., 2019). Thermal coagulation and cutaneous laser therapies are susceptible to skin damage as well as hypopigmentation or hyperpigmentation (Goldman, 2002; Piazza, 2014).

Sclerotherapy

Sclerotherapy, also known as endovenous sclerotherapy, uses chemical agents, which is injected to superficial veins, in response to which endothelial inflammation occurs, resulting in fibrosis and closure of veins. Sclerotherapy is an indication for small 1–3 mm and medium sized 3–5 mm VVs as well as for postsurgical recurrent VVs. Precise diameter is however not a clear-cut criterion to make treatment decisions (Raetz et al., 2019). Complications of sclerotherapy include allergic reactions to sclerosants, hyperpigmentation (if performed during seasons of high sun exposure), superficial bluish thread-like capillaries or matting, cellulitis, and in rare conditions, ulceration or thromboembolism. Additional hospital visits may be required to treat areas of trapped coagulum. A cosmetic improvement can be found in 70% of patients through sclerotherapy (Goldman, 2002; Piazza, 2014). To achieve the best results, CS needs to be worn for 7–10 days after sclerotherapy (Kern, Ramelet, Wütschert & Hayoz, 2007).

Surgery

Previously, the surgery with either ligation or stripping was considered as standardized treatment after the failure of conservative measures. However, in recent era, other latest techniques are available as treatment options. Further, literature available does not consider surgery as the best treatment option for VV. According to the NICE guidelines, surgery is considered as third line of treatment after sclerotherapy or thermal ablation (Raetz et al., 2019).

Ayurvedic management

In Ayurveda, VVs are known as Siragranthi. According to Ayurvedic concept, VVs are caused due to Vataprakopaka nidanas (factors which aggravate Vata) such as heavy or excessive exercise, physical exertion, and straining which causes obstruction of the veins of debilitated person which in turn causes Sankocha or compression, Sampeedana or squeezing, and Vishoshana or drying up and produces Granthi (protruded nodule-like structure). Virechana (therapeutic purgation) followed by Raktamokshana (bloodletting) along with internal medication with Manjishthadi Kwatha and Kaishore Guggulu is found to be effective in the treatment of VV (Bramhanwade, Jena, Bahute, Bhatted & Dharmarajan, 2021).

Hirudotherapy (medicinal leech therapy) is used to treat a number of disorders, which accompanies pain as one of the symptoms. Saliva of leech contains important constituents such as hirudin and calin, which are anti-inflammatory, anticoagulant (inhibit acetylcholine), and thrombolytic and has circulation-improving properties. This therapy involves introduction of leech's saliva in injectable form into the patient while withdrawing blood from the patient. It is considered to have analgesic property as well. Leech therapy is found to be effective, fast pain reliever with long-lasting effect (Koeppen, Aurich & Rampp, 2014).

The Ayurvedic drug Gotu kola is known to treat a large number of skin ailments and also promote vein health and therefore is effective for VV also (Tiwari, Gehlot & Gambhir, 2011; Shruthi, 2019). Another herb Tagetes erecta has been scientifically proven to manifest antioxidant, analgesic, and antibacterial properties and also promotes healing, thus used in VV also. Traditional physicians of Sri Lanka effectively treat VV by Raktamokshana, paste of fresh leaves of Dahaspethiya (T. erecta), and Maduruthala Koththamalli, Wandu Thambuma (Ocimum sanctum and Coriandrum sativum) (Wickramasingha & Ediriweera, 2018).

Management with Yoga

Though there is no direct study that shows the effectiveness of Yoga in VVs condition, few studies indicate effectiveness of Yoga as a therapy in vascular health.

It has been documented that psychological stress causes transient endothelial dysfunction even in healthy individuals. Further, psychological stress causes reduced bioavailability of nitric oxide, resulting in increased vascular tone, aggregation of platelets, as well as upregulated adhesion molecules (Ghiadoni et al., 2000). A 6-week pilot study shows the effectiveness of Yoga and meditation on endothelial function in individuals with coronary artery disease (Sivasankaran et al., 2006). It has also been well documented that endothelial dysfunction also occurs in chronic venous disease including VV condition (Castro-Ferreira, Cardoso, Leite-Moreira & Mansilha, 2018). Yoga and meditation may help in improving endothelial function related to VVs by reducing psychological stress.



A study was performed on nonpregnant women aging between 35 and 65 years to find out the benefits of grounding or earthing while performing mild form of Hatha Yoga practices (Brown & Chevalier, 2015). The hypothesis of earthing states that when direct skin contact is made outdoors or indoors (through grounded system), the electric potential of body becomes same as that of earth's electric potential due to which the body can receive continuous ground's negative charge in the form of electrons, which is needed for optimum functioning of many physiological processes and also makes a reservoir of antioxidant electrons for future use (Applewhite, 2005; Oschman, 2007; 2009). The particular research concluded that the readings of the participants performing grounded Hatha Yoga practices have shown lower levels of inflammation as well as reduced blood viscosity, and also blood viscosity is considered as early predictor of chronic disease (Brown & Chevalier, 2015). In case of VV condition, increased procoagulant activity (increased fibrinogen and hemoglobin) and higher levels of inflammatory markers (interleukin-6) are seen in VV blood as compared to that of systemic blood constituents (Satyendra et al, 2020 Tiwary et al, 2020.). Hence, from the above research, we may estimate that grounding Hatha Yoga practices may prove effective in varicose veins individuals by reducing free radicles, inflammation, as well as blood viscosity.

We also have a couple of studies which suggest the benefit of exercises on VV condition. Exercise therapy is much closer in similarity with Yogic techniques, which suggest that Yogic techniques will definitely help in improving symptoms of VV condition, but further researches need to be done in this direction.

Management through exercise

Moderate-intensity lower limb exercise training (treadmill walking exercise) over the postsurgical VV patients shows improvement in microvascular endothelial function in 8 weeks (Klonizakis, Tew, Michaels & Saxton, 2009). Another study confirms the effectiveness of aquatic (hydrotherapy) exercise in reducing pain severity and quality of life in females with VVs (Momeni Mehrjerdi, Ravari, Attarzadeh Hoseini & Khoshraftar Yazdi, 2015).

In a study, Buerger Allen exercise was performed by VV individuals twice a day for 10 days. The majority of participants had shown significant reduction in pedal edema by performing the exercises (Parimala & Priya, 2019). Another study was performed by postpartum women with VV to explore the effect of calf muscle exercises. Participants were randomly divided into two groups. Experimental group performed calf muscle strengthening exercises and also used CS. Control group used only CS. Both the groups were taking medicines as prescribed by physician. At the end of the study, exercise group had shown significant reduction in inner diameter of great saphenous vein at both knee and ankle level as compared to control group, which shows effectiveness of calf muscle strengthening exercises in VV condition (Helal et al., 2016). In addition, a study has shown a significant reduction in reflux volume (−40.9%) and also reflux time, after particular set of exercise for 60 s (30 toe raisings at the rate of 1 time per second), indicating positive effect of exercise on VV individuals (Tauraginskii et al., 2019).


  Discussion Top


VVs are common in Indian population, but reported prevalence is much less due to negligence and lack of awareness about the problem (Kiran Shankar, 2017). Although there are many therapies available for managing VVs and its complications, but most of the conventional treatments such as surgeries as well as other minimally invasive techniques and ablations causes one or the other side effects (Goldman, 2002; Piazza, 2014). Ayurvedic therapies with Ayurvedic drugs, herbal formulations as well as leech therapy has anti-inflammatory, anticoagulant (inhibit acetylcholine), and thrombolytic properties effective in VV condition (Koeppen et al., 2014). Exercise as well as Yogic techniques can be a better treatment option without creating any ill effects and is cost-effective also. Evidence shows that lower limb exercises strengthen calf muscle pump function (Padberg, Johnston & Sisto, 2004) and improve ankle joint mobility (Szewczyk et al., 2010), leading to improved venous return (Yonezawa et al., 2015) and reduction in venous hypertension (Padberg et al., 2004) which in turn causes improved valvular functions (Bergan et al., 2006). Reduced venous hypertension along with improved valvular function also improves shear stress (Tanaka et al., 2006) on endothelial layer of blood vessels, resulting in reduced endothelial damage (Bergan et al., 2006). As the endothelial damage reduces, the reduction in local inflammation as well as free radical formation occurs (Tanaka et al., 2006; Bergan et al., 2006), thereby improving in venous condition and helping one to effectively manage the condition. As exercise therapy and Yoga are complementary to each other, the positive effect of exercise indicates effectiveness of Yoga in VV condition. There are no direct studies proving the effectiveness of Yoga therapy in VV condition, but few studies can indicate correlation between Yoga and venous condition. Yoga and Pranayama reduces psychological stress, leading to improved endothelial function of the veins (Sivasankaran et al., 2006), which may be helpful in venous condition. In addition, grounding Hatha Yoga practices improves continuous ground's negative charge in the form of electrons and also creates antioxidant reservoir in practitioner's body (Applewhite, 2005; Oschman, 2007; 2009), which reduces inflammation as well as blood viscosity (Brown & Chevalier, 2015) which may be helpful in VV condition. The probable mechanism showing effect of Ayurveda, Yoga, and exercise is depicted in [Figure 2]. In future, lots of studies are required to show the effectiveness of Yoga in VV condition to help the individuals suffering from this particular health issue.
Figure 2: Probable Mechanism of effect of Exercise, Yoga and Ayurveda on Varicose vein disease.

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  Conclusion Top


Ayurveda can be an alternative therapy in VV. In addition, there are many studies that prove that exercise therapy is effective in VV disease. Some Yogic studies indirectly prove effectiveness of Yogic procedures in VV condition. As the exercise and Yoga therapy are complementary to each other, Yoga can be a proven therapy in prevention and treatment of VV. There is urgent need to do large number of clinical trials to prove the effectiveness of Yoga in VV condition.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.[47]



 
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