Definition of Varicose Veins
Varicose veins are a common condition, affecting more than 50% of people in the United States. They occur in both men and women; however, women are more commonly affected. It is estimated that 60% of women and 40% of men will suffer from the condition at some point in their adult lives. While the condition is more pronounced in the elderly, it can develop much earlier in life. Varicose vein have a significant impact on quality of life and are a financial burden on both the individual and the healthcare system. Symptoms such as leg pain, fatigue, restlessness, and night cramps have been shown to decrease quality of life. Furthermore, the cost of treatment for venous disease is estimated at $1.4 billion annually. This figure surpasses the cost of treating arterial disease and deep vein thrombosis. Unfortunately, varicose veins are often overlooked as a benign and self-limited disease, and the prevalence is underestimated. Awareness of the condition is a key factor in encouraging further research and development of management strategies.
Importance of Addressing Workplace Factors
Knowledge of the associated risks may also be useful in identification of individuals who might benefit from early medical intervention to prevent long-term damage to their veins. This would enable primary care to be better directed at those at high risk of vein disease and better use of healthcare resources overall.
In addressing the importance of workplace factors, it is apparent that there is a vast array of causative factors which contribute to varicose veins. Increased knowledge of primary or principal causation of varicose veins would enable better preventive measures to take place. This would involve attempting to modify the person or the duration of the causative activity and would only be possible if other alternative employment was available. Prevention of causation may also prevent occurrence and recurrence of varicose veins. This is particularly important in trying to eliminate or alleviate varicose veins in occupations with high risk factors. An example would be in heavy manual labor, where an older employee could be moved to a supervisory role providing there was no reduction in salary or status. Similarly, such knowledge could be useful in determination of workers compensation for those who develop varicose veins as a result of certain working conditions.
In this day and age, the economy plays a crucial role in fueling the professional outgrowth and development of its citizens. With the increase in job opportunities and entrepreneurship, longer work hours, higher salaries, and good work conditions remain an element of hope. However, behind the veneer of hope lies a noticeable absence in attention to the adverse health effects on workers predisposed to occupational hazards. In particular, varicose veins, a chronic condition affecting a large number of individuals worldwide, has been attributed to a variety of occupational conditions that involve prolonged standing and sitting. Studies have shown that occupational risk factors for varicose veins include prolonged standing, lifting heavy objects, intense physical exertion, bending of the knee, and work in a hot environment with the absence of moderation breaks to rest and elevate the legs. These risk factors are commonly attributed to domestic work settings, nursing, and half of all varicose veins patients are nurses or architects. It is generally recognized among people that varicose veins are caused primarily by prolonged standing. This has been imprinted by tales of generations of workers in factories.
Causes of Varicose Veins
Perhaps the most well-known cause of varicose veins is prolonged periods of standing, usually due to occupation. Health professionals have always been thought to be one of the highest risk groups and a study in Edinburgh showed the prevalence of varicose veins amongst nurses to be 20-60%. Other groups at high risk include teachers, hairdressers, chefs, and factory workers. The increased pressure on the veins caused by standing stagnates the blood by preventing the natural action of muscle pump contraction. This eventually leads to the veins becoming distended and varicosed. Conversely, prolonged sitting can also be a cause, although sitting exerts much less pressure than standing, the effect is cumulative and by the time symptoms develop it is often too late to change careers. This is the situation with many professionals such as secretaries, receptionists, and lorry drivers.
Varicose veins are a condition that is thought to affect between 50-70% of people, although only a small percentage of sufferers will need invasive treatment such as surgery. Research has shown that they are a condition that is deeply rooted in our genetics and inherited predisposition is a very strong risk factor. A study of 2104 pairs of female twins published in 1999 in the Journal of the American Medical Association showed that genetics accounted for between 65-72% of the variation in whether an individual develops varicose veins. Though there is no known genetic mechanism by which varicose veins are inherited, various family studies have shown that individuals whose family members have varicose veins are much more likely to develop them than someone who has no family history of the condition.
2.1 Genetic Predisposition
Maternity leads to a 3-fold increase in VV prevalence, so female sex hormones have been shown to dilate veins and affect vein valve function. Hence, it is conceivable that hormonal medication influences VV. This suggests that an occupation in the pharmaceutical or healthcare industry where the worker is handling hormone medication could lead to the development of VV, as they could have higher exposure to hormonal substances than the general population. Nevertheless, occupational factors related to female hormones are an uncommon cause of VV in men, and women have equal genetic susceptibility to the condition. Therefore, the influence of hormonal medication is of lesser importance in comparison to inherited vein wall or valve abnormalities.
It has been suggested that genetic predisposition plays a partial role in the susceptibility to VV. There is overwhelming evidence that VV is a condition that runs in families. 70% – 80% of all patients with VV have parents who also suffered from the condition. Twin studies in particular have shown that there is a genetic predisposition. Therefore, it is not necessarily the environmental circumstances that have caused the condition, it’s merely exacerbated it. Family history of VV is a candidate for future genetic analysis to elucidate its precise mode of inheritance. Further research is required to identify the genes responsible for VV, but it is likely that inheritance of a weakened vein wall and vein valve incompetence are important factors. Heavily laden iron stores and subsequent increased oxidative stress may cause inflammatory changes within the veins and valve damage, and so genetic hemochromatosis is another potential genetic cause of VV.
As varicose veins (VV) are a common chronic venous disorder which causes the veins to be abnormally enlarged and twisted, it is important to understand the causes of VV. There are a number of theories that have been suggested to cause VV. The principle of this essay is to address workplace factors. Therefore, the theories that will be discussed will be those with a link to causing VV within the workplace. This is because a workplace injury is defined as any injury or disorder sustained by a person in the course of their employment, and a work-related injury means an injury resulting from a workplace accident or from exposure to a physical or psychological occupational hazard.
Prolonged Standing or Sitting
Scurr et al. also emphasizes the need for further research of this nature to aid in the prevention of varicose veins in the workplace, and to help determine better health and safety guidelines for persons already suffering with the condition.
Laboratory studies conducted by Scurr et al. have attempted to simulate the pressure changes in the veins, and the effect of this upon varicose vein patients as compared with healthy persons, with a view to gaining a better understanding of the progression of the disease. Using a water tower model to increase the pressure in the veins of healthy persons, and comparing this with the pressure generated by standing and leg muscle exercises in varicose vein patients, the study aimed to quantify the potential damage caused by increased pressure in the veins. Measurements taken from the varicose vein patients showed a tenfold increase in microscopically filtered dye appearing from superficial veins in the legs, indicating possible damage from a long-term increase in venous pressure. This suggests a link between varicose vein progression and the increased pressure in the veins provoked by standing.
The National Heart, Lung and Blood Institute has suggested, however, that while excessive standing may not be a cause of varicose veins, it can be a contributing factor to their development in persons already suffering with the condition. This is due to the added pressure on the veins in the legs associated with standing, as the pressure generated by body weight alone is already three times that of lying down. This increased pressure leads to an increased likelihood of blood pooling in the legs, and in persons where the valves in the veins are weakened and not functioning properly, this can exacerbate the already defective blood flow and cause further distention of the veins.
The section titled “Prolonged Standing or Sitting” seeks to uncover whether these postural situations incurred by workers can lead to an increased risk of varicose veins. The medical evidence has been conflicting in the past, with some studies indicating a particular association between prolonged standing and the development of varicose veins, and others failing to identify any risk.
Lack of Physical Activity
It is an interesting point that athletes are less likely to be diagnosed or to be symptomatic from varicose veins. The thought is that with increased muscle tone and overall improved fitness, there will be increased transmission of force from superficial veins to the deeper veins at the muscle pump. This is a very important mechanism that reduces the pooling and reflux that is present with varicose veins. Another effect of regular exercise can lead to a reduction in body weight and less strain on the lower limbs, which can prevent the varicose veins from worsening over time and reduce the risk of further venous disease.
This is most commonly seen in people who have had occupations that involve a lot of standing. The pooling of blood that is present with varicose veins is more likely to happen if a person is standing or sitting, as blood does not flow as efficiently. A study has shown that people who are sitting are more likely to get varicose veins, which is a bit of a contradiction. Lack of physical activity is thought to be a cause, as people who are sitting or standing and not moving for long periods of time are more likely to develop the condition compared to people on their feet who are moving around a lot. Also, with static standing, it increases the venous pressure and people will probably be more likely to have an increased body mass index. This condition is an aggravating factor for varicose vein development. With increased weight, the pressure in the veins can increase, which can cause veins to dilate and cause the unidirectional valves to be incompetent. This would not help the situation of someone already suffering from pain from varicose veins. The reason for this is that an increase in blood vessel length and vein volume, and this is an ideal environment for varicose veins to be formed.
Occupational Risks for Varicose Veins
Deep vein thrombosis is also a risk for those who spend a lot of time sitting. It is the formation or a partial blockage of a blood clot in a deep vein. This can lead to acute leg pain or swelling, but on some occasions, it is completely symptomless. The most serious complication is that part of the clot may break away and travel to the lungs. This is known as a pulmonary embolism and can be fatal if not treated.
In advanced cases, there may be the formation of a venous ulcer, which is an extremely severe form of varicose veins. It is an open sore on the skin, which results from a long-term buildup of tissue fluid in the affected area. This causes inflammation and damage to the tissue around the area and may or may not be painful. Venous ulcers most commonly occur on the inside of the leg above the ankle and are an unpleasant and potentially serious condition.
During real phlebitis, there is a possibility of healing if the vein is not completely blocked. This is achieved by the growth of endothelium into the lumen, thus preventing blood from leaking into the tissue. The exact same process is what causes the sealing of varicose veins operations that remove the varicose vein from the tissue.
With prolonged standing, there is added stress on the veins as the valves are under constant pressure from the force of gravity. In the early stages of varicose vein formation, it may result in swollen and/or painful ankles. This is known as post-phlebitis syndrome, a reversal of the flow of vein from deep to superficial veins. It is caused by damage to the valves but it is still a form of varicose veins.
Jobs requiring prolonged standing can contribute to the development of varicose veins. Blood flows in the deep veins of the legs only with the help of the calf muscles and the veins with one-way valves. When the calf muscles stop working, there is a prolonged rise in venous pressure. It is this increase in pressure of the segment of vein below the valve that causes the formation of the vein.
Jobs Requiring Prolonged Standing
Job situations demanding long hours of standing place any person at a higher risk for varicose veins. The comparison between sitting and standing is still a relatively less examined area, yet the results in most studies indicate that a person standing is at a higher risk than a person sitting. Prolonged standing increases the pooling of blood in the legs, which in turn may cause chronic venous insufficiency, varicose veins, and increase the risk of deep vein thrombosis. Studies have indicated that there is a two to fourfold increase in risk of getting deep vein thrombosis after surgery in the general population exposed to prolonged sitting or standing, with another study showing that prolonged standing increased the likelihood of getting a venous disorder that may lead to a clot by threefold. This risk is not just confined to older workers/surgery patients or to those with a prior history of vein disorders. A study examining Danish military recruits found that the recruits who had to stand at attention for long periods had a higher likelihood of getting varicose veins later in life than the general population. This evidence indicates that prolonged standing is a significant risk to the development of varicose veins and may influence younger persons to be more affected than in previous generations.
Jobs Requiring Prolonged Sitting
An estimated half of the British workforce spends most of the working day seated, which is not much different from other industrialized countries. Typists, lorry drivers, civil servants, bank cashiers, and many others spend hours at a time sitting in the same position. Most industrialized countries have large numbers of workers who spend most of their working day sitting, and this provides a large number of potentially exposed people. Even though sitting and standing both cause increased pressure in the veins compared to lying, it seems that prolonged sitting is much less likely than prolonged standing to cause the development of or aggravation of pre-existing varicose veins. This could be because when we sit, the hip and knee joints are flexed, and this helps to retard the pooling of blood in the legs. Consequently, there has been little research into occupational sitting and varicose veins. An important consideration when thinking about seated work is the future health risks on the cardiovascular system. It is also well known that more time spent sitting is linked to an increased risk of stroke and heart attack. Therefore, although prolonged sitting is not considered a causal factor in the development of varicose veins, it is likely to be a consideration in relation to the continuation of seated work and its impact on other health issues.
Heavy Lifting and Straining
Heavy lifting and straining have been cited by many authors as important risk factors in the development of varicose veins. The most severe occupational manifestation of the etiological significance of heavy lifting is probably seen in miners. In a survey of 300 South Island coal miners, it was found that nearly half had developed varicose veins before the age of 25 years. This compared with a 10% incidence in a group of control subjects matched for age and social class. In a further survey of 2239 men and 689 women who had worked in the New Zealand mining industry at some time between 1950 and 1978, it was found that the relative risk of hospitalization for varicose veins compared with the general population was 2.2 for men and 10.0 for women. In more recent times, the importance of lifting in the etiology of varicose veins has been confirmed by a case-control study from France in which the subjects were a group of 90 patients with confirmed pelvic varices and a control group of 94 attending the same hospital for various minor surgical conditions.
Exposure to Vibrations
Vibrations in the jobs or the machines have a potential harmful effect on the vascular system. Conditions and diseases like Raynaud’s syndrome and vibration-induced white finger have a direct relation to the exposure to hand-transmitted vibrations. A study has concluded that exposure to a vibratory environment at the workplace remains associated with an increased occurrence of VV and has found a clear dose-response relationship with ‘cumulative’ exposure to hand-transmitted vibration from tools. Those who work with vibrating hand tools for one-third or more of their time have the highest risk. Premature atherosclerosis has been seen in workers exposed to whole-body vibrations due to changes in hematological and lipid profiles of the body. Research has shown that the peak systolic blood flow in the great saphenous vein at the ankle reduced almost to half after exposure to vibration, as compared to the variable magnitude in normal subjects. This is because the fatigue in the vessel due to vibration averaged an increase of 1.3mm of the great saphenous vein diameter in the subjects, showing the effect of vibration. With prolonged exposure, it can lead to the progression of varicose veins.
Addressing Workplace Factors to Prevent Varicose Veins
Regular breaks and physical activity are also essential components to prevent the onset or progress of varicose veins and venous disorders. Occupational tasks that require prolonged sitting or standing have been positively associated with venous symptoms when compared to individuals who had jobs that involved frequently changing body positions. Prolonged sitting or standing reduces the effectiveness of the muscle pump and therefore increases the pressure on the veins and capillaries, so it is important that those who have these types of occupations take regular breaks to mobilize and change body positions. A study of 247 sedentary office workers identified that those who took more short breaks had a lower degree of varicose vein severity than those who took fewer or longer breaks. Although the type, frequency, and intensity of physical activity and occupational task is likely to influence varicose vein development in different ways, there is strong evidence to suggest that regular involvement in some form of moderate-intensity physical activity can decrease the risk of varicose veins and the symptoms associated with it.
Orthostatic work postures can place increased pressure on the capillaries, commonly in the lower limbs, which can lead to pooling of the blood and increased risk of developing varicose veins or edema. Ergonomic workstation design has been suggested as a preventative measure, as it allows the worker to alternate between sitting and standing and therefore alleviate the pressures of prolonged standing. Prolonged static standing has been suggested as a risk factor for varicose veins as it increases the forces on the venous structures in the legs. By alternating between sitting and standing, the worker breaks up the static posture that can exacerbate the development or progression of venous disorders. When workers were informed and encouraged to use the sit-stand workstations, it was reported that 58% of workers experienced less leg discomfort by the end of the day and 62% felt more productive during the three-month intervention period.
Ergonomic Workstations and Equipment
Ergonomics is the study of how a person’s environment and the equipment he or she uses can most effectively be designed for the highest level of safety, efficiency, comfort, and productivity. When applied to the workforce, the objective of ergonomics is to design the job to fit the worker – rather than forcing the worker to fit the job. By matching the task to the worker, ergonomists believe that the risk of musculoskeletal disorders (MSDs) can be reduced. The term MSD is used to describe an injury to the muscles, tendons, ligaments, joints, nerves, blood vessels, or other soft tissues, usually caused by using the body in a way that places stress over time on an affected body part. Subjects of varicose veins and telangiectatic venules often fall under the category of MSD. This concept is supported by the fact that jobs in certain industries pose higher rates of venous disorders due to the nature of the work that is being performed. It has been suggested that individuals working in manual labor jobs and nursing have higher rates of experiencing varicose veins. This may be due in large part to the excessive amount of standing and sitting, heavy lifting, and the use of assistive equipment. An analysis of job duties and how they affect the progression of varicose veins is critical in finding an appropriate intervention for prevention. The results of such studies may lead to a redesign of the job and/or tasks, altogether eliminating harmful factors or finding a suitable replacement. This is especially important in nursing, where according to certain tasks such as prolonged standing, in which venous pooling is at its greatest, cannot be eliminated.
Regular Breaks and Physical Activity
In jobs where it is not possible to change the nature and pace of the work, studies have shown that there is a reduced risk of varicose veins in people who engage in regular physical activity outside of working hours. This is due to the positive effects of exercise on the calf muscle pump and muscle tone. However, care should be taken as high-impact activities and heavy weight lifting have been shown to have a negative effect in a small number of cases, where they have increased the severity of the varicose veins. This is believed to occur because the increased blood flow pushing against the already competent varicose veins causes further damage to the vein walls.
Workers who are required to stand in one position for prolonged periods are advised to change positions as often as possible, as well as to stretch the muscles. Proprioceptive exercises, such as standing on one foot or doing small knee bends, are particularly useful for promoting good circulation. Jobs that involve prolonged sitting require two to five minutes of walking or light leg exercise every half hour, and all workers should take a break during their lunch period to engage in an activity that they enjoy.
Supportive Footwear and Compression Stockings
Supportive aid, such as compression stockings, is a conservative treatment to help prevent the progression of varicose veins and manage the symptoms. Graduated compression stockings are very tight at the ankle and become looser as they move up the leg. This creates a pressure gradient, which helps improve the vein valve function and aid the return of deoxygenated blood to the heart. It is very important to wear compression stockings properly. The correct fitting and compression strength are vital. An incorrect size can exacerbate the condition. A vein specialist is the best person to advise on the type of compression and how long they should be worn. Similarly, wearing supportive footwear can also ease the pain caused by varicose veins. A study of women from the Nurses’ Health Study found that long-term standing and working as a health professional were not associated with an increased risk of developing varicose veins. This challenges the popular belief that prolonged standing is a risk factor for varicose veins. Instead, it suggests that other causes of prolonged standing, like uncomfortable footwear, affect the development of varicose veins. Measures to relieve the discomfort caused by varicose veins can include trying to sit in short spells whenever possible with the legs raised above the level of the heart. This can be done especially at night to relieve any swollen ankles or symptoms of restless leg during sleep.
