chronic venous insufficiency ( cvi ) is characterised by the retrograde flow of blood in the 
 lower extremity .
cvi and its sequel of varicose veins and venous hypertension are among the 
 most common disorders that affect daily life1 .
the annual incidence of cvi is 26% and 1.9% in women and men , respectively2 .
the main risk factors for cvi include family history , prolonged standing , history of deep 
 venous thrombosis , age , obesity , and pregnancy2 .
the venous hypertension of cvi usually begins with oedema and 
 varicose veins and progresses to stasis cellulitis and pigmentation of skin leading into 
 lipodermatosclerosis and ulceration3 .
since established venous insufficiency can not be cured by pharmacological interventions 
 alone , it is most commonly treated by non - invasive methods4 , 5 .
the compression therapy 
 relieves cvi symptoms by improving venous function and hence is preferred among other 
 physical therapies to treat venous and lymphatic insufficiency of lower limbs .
the 
 compression stockings ( cs ) and calf muscle pump exercises increase venous return and are 
 mainstay of conservative treatment4 , 6,7,8 .
ct exerts the highest compression at the ankle which gradually decreases towards knee , 
 thereby ensuring the upward flow of blood in the direction of heart and preventing reflux 
 towards foot or in lateral superficial veins .
the compression pressure gradient of cs , by 
 reducing diameter of major veins , increases velocity and volume of blood flow and decreases 
 the venous hypertension and symptoms9 , 10 .
cvi considerably affects patient s health - related quality of life ( hrqol ) . in many 
 patients ,
the pain and discomfort of cvi affects physical mobility , working capacity and 
 social life11 .
the international society 
 for vascular surgery recommended to expand outcome measures for venous disease studies to 
 include patient - reported measures of functioning and hrqol .
it noted that comprehensive 
 evaluation of venous disease should include assessment of clinical outcomes and hrqol12 . for chronic conditions like cvi
, the 
 assessment of hrqol can provide important information on disease burden that may not be 
 adequately captured with traditional physician - based measures of morbidity or mortality13 .
due to chronic nature of cvi , the long term usage of the cs may be rough considering the 
 compliance of the patient .
therefore , the present study was aimed to analyse the effect of 
 short term use of cs on symptoms of cvi and hrqol in cvi patients .
the patients visiting outpatient clinic , at department of cardiovascular surgery , abant 
 izzet baysal university hospital bolu , turkey were enrolled in this study .
the study was 
 approved by the clinical research ethics committee of abant izzet baysal university faculty 
 of medicine ( ib.30.2.ab.0.20.05.04050.01.0460 ) .
inclusion criteria were patients without prior treatment for cvi or varicose vein surgery 
 and for those the disease was categorised as c2 and c3 according to ceap classification . 

exclusion criteria included presence of deep vein thrombosis , congestive heart failure , 
 malignancy , patients having more advanced skin changes such as lipodermatosclerosis skin 
 ulcers or other dermatological disease with pruritus , and patients who had ongoing use of 
 cs .
all patients enrolled were given detailed explanation of the study following which informed 
 consent was obtained from them . a questionnaire including demographic information , 
 occupational details , and relevant medical history
the generic , 
 disease specific hrqol , and depression - related questionnaire was requested from 126 
 patients .
the turkish version of nottingham health profile ( nhp ) was used to measure a generic hrqol . 

it contains 38 questions with assigned individual score from six different categories such 
 as energy level ( el ; n=3 ) , pain ( p ; n=8 ) , emotional reaction ( er ; n=8 ) , sleep ( s ; n=5 ) , 
 social isolation ( si ; n=5 ) , and physical abilities ( pa ; n=8 ) .
for calculation of final score in each category , variation in number 
 of items per category was rationalised by computing percentage score ( i.e. , each sum was 
 multiplied by 100 and divided by the number of items in the category ) .
possible scores 
 ranged from 0 ( indicating all  no  answers in that category or absence of distress ) to 100 
 ( all  yes  answers indicating maximal distress ) .
the questionnaire on 26 items from 2 categories of veines - qol / sym measured severity of 
 symptoms of cvi and its impact on hrqol from patient s perspective .
the five different 
 frequencies ( always , a few times a week , once a week , once in a few weeks , and never ) for 
 symptoms fullness of lower extremities , pain , swelling , night cramps , heat / burning 
 sensation , restless legs , itching , tingling / stinging sensation , and throbbing under 10 
 different items were assessed .
limitations in daily activities ( 9 items ) , greatest intensity 
 during the day ( 1 item ) , change over the past year ( 1 item ) , and psychological impact ( 5 
 items ) were covered by the hrqol scale of 2 to 7 points for response on intensity , 
 frequency , or agreement .
the highest score indicated better outcomes in 
 veines - qol and on veines - sym scale .
veines - qol / sym ; turkish validity and reliability were 
 established by study of kutlu et al15 .
the beck depression inventory ( bdi ) consists of 21 items ; it is a self - report rating 
 inventory that measures characteristic of attitude and symptoms of depression .
the study group included 
 44 patients who regularly used cs and remaining 82 patients who did not use cs were included 
 in control group .
the class 2 cs ( jobst brand ) of 
 height below knee and pressure gradient of 2332 mmhg were used .
the patients were asked to 
 wear cs as soon as they wake up in the morning and take it off before going to bed .
they 
 were asked to use cs for a period of four weeks , exercise regularly and apply skin care 
 moisturiser ( ph 5.5 ) .
the exercises prescribed were ankle pumping and heel lifts ( 3 sets of 
 10 repeats ) and daily walk of 3045 minutes .
the patients were warned that they should not 
 wear cs while sleeping due to high resting pressure .
the patients ( without use of cs ) in the control group were also prescribed same exercises 
 and skin care .
all assessments were repeated after a four - week treatment . the statistical program for social sciences ( spss 18.0 , spss inc . ,
quantitative data were presented as mean and standard 
 deviation and qualitative data as percentage ( % ) and frequency ( n ) .
an independent t - test 
 was used to compare the differences in venous symptoms , depression and hrqol scores between 
 groups .
of the 203 patients with cvi interviewed for this study , 77 were excluded due to habitants 
 of town or village ( n=33 ) , absence of inclusion criteria ( n=27 ) , and rejection to 
 participate into study ( n=17 ) .
the remaining 126 patients were enrolled into the study : 
 study group ( n=44 ) and control group ( n=82 ) .
nine patients ( 2 from study group and 7 from 
 control group ) did not undergo last evaluation .
thus , the study was completed with 117 
 patients ( 73 females and 44 males ) : study group ( n=42 ) and control group ( n=75 ) .
the average 
 age of patients was 60.9  9.4  years in study group and 63.1  4.9  years for patients in 
 control group .
the height ( cm ) , bodyweight ( kg ) and body mass index ( bmi ) ( kg / m ) for 
 patients in both groups were comparable ( table 
 1table 1.demographic and clinical features of the patientsstudy groupn=42x  sdcontrol groupn=75x  sdage ( years)60.9  9.4 63.1  4.9*height ( m)1.63  0.51.63  0.0weight ( kg)81.1  11.679.8  9.5bmi ( kg / m)30.2 
values are mean  sd , * p<0.05 there were significant differences between groups for veines / sym sub - parameters , nhp , bdi , 
 veines - qol and veines / sym total scores before and after receiving treatment ( p<0.001 ) 
 ( table 2table 2.comparison of differences for veines - qol , nhp and bdi measurements of the 
 patients between groups ( n=117)study groupn=42x  sdcontrol groupn=75x  sdveines
18.2*bdi3.8  8.2 1.3  1.6**values are mean  sd , * p<0.05 ) . furthermore , pre- and post - treatment total score differences for each group 
 were evaluated and maximum differences were found in study group for the scores of nhp , bdi , 
 veines - qol , and veines / sym ( table 3table 3.comparison of pre and post treatment scores for groups ( n=75)pre treatmentpost treatmentx  sdx  sdveines / symstudy group22.4  7.528.5  9.7*control group29.2  10.127.6  9.8*veines - qolstudy group67.8  13.376.7  15.5*control group76.8  16.773.3  16.0*nhpstudy group213.8  157.1166.1  124.2*control group182.0  118.6198.0  120.5*bdistudy group11.0  8.57.1  7.7*control group12.1
* values are mean  sd , * p<0.05 * values are mean  sd , * p<0.05
the present study showed that short - term use of cs in cvi patients has decreased symptoms 
 and significantly improved quality of life in these patients .
the compression treatment for venous insufficiency in lower extremity has been used for 
 hundreds of years since hippocrates . the compression treatment that applies
the reduction in venous reflux due to application of compression below knee is well 
 known19 . in 112 cvi patients , the use 
 of cs ( pressure 3040 mmhg ) for one month significantly improved lower extremity pain , 
 oedema , activity tolerance , depression , sleep disorders and qol9 . in this study , cs of below knee length
was preferred due to 
 its comfort , improvement in cs calf muscle pump , and low cost .
cs decreases venous symptoms such as pain , oedema , stasis , and skin changes20 .
the venous symptoms were improved by the 
 use of class 2 ( 3040 mmhg ) and class 3 ( 4050 mmhg ) cs for six weeks21 .
similarly , a significant decrease in symptom severity 
 ( pain , depression , swelling , sleep ) and increase in activity tolerances were observed in cvi 
 patients after use of cs for one month9 . 
 the use of cs improved pain and symptoms in 90% patients with cvi22 . in line with this ,
the decrease in venous symptom scores 
 suggests importance of short - term cs usage .
the difficulty in wearing cs , financial burden , discomfort of heat and tightness of 
 stocking are responsible for low compliance of cs use in cvi patients .
based on review of 
 patients self - report , the mediterranean climate characteristics of hot weather , high cost 
 of compression stockings , and difficulty to wear were the possible reasons .
it is known that venous 
 hypertension increases after removing stockings . in a study comparing the duration of cs 
 usage ,
the use of cs for entire day is more beneficial than for only half day24 . in order to decrease ambulatory venous 
 hypertension and to obtain maximum benefits ,
patients were asked to wear cs all day long . 
 the cs usage in patients was regularly checked via telephone interviews .
although venous diseases are highly prevalent , its effect on daily activities and quality 
 of life are not investigated thoroughly .
both general and disease - specific qol are accepted 
 as a standard to determine changes in qol .
the qol measurement enables better understanding 
 of impact of the disease while evaluating specific problem25 . in this study ,
disease - specific qol was assessed along with veines - qol whereas general qol 
 was assessed with nhp . at the end of one month
, significant improvement was observed in 
 venous symptoms , veines - qol scores and nhp parameters in group that used cs than that did 
 not use cs .
thus cs usage improved overall qol suggested by improvement in both 
 disease - specific and general qol scores . in earlier study ,
the use of two different cs for a two - week duration was found to be 
 beneficial for qol in both groups26 .
the 
 use of class 1 ( 1015 mmhg ) cs for four weeks significantly increased qol compared with and 
 placebo pressure ( 36 mmhg ) stockings27 . 
 in a similar study , it was observed that a four - week use of cs increases qol and improves 
 symptoms of cvi28 .
the decrease of qol in cvi is based on physical function and mobility in addition to 
 depression and social isolation .
depression limits performance in physical , social , and 
 personal activities leading to disability27 .
it was reported that 68% of the patients with venous ulceration 
 suffer fear , depression , social isolation , anger , anxiety , and negative self - image29 . however , there is inadequate research on 
 evaluation of depression level in venous diseases and use of scales in directly evaluating 
 depression . in earlier study in patients with venous ulcers and bdi ,
the scale is used to 
 determine presence of various levels of depression30 . in this study ,
depression was assessed by bdi and short - term use 
 of cs decreased venous symptoms in cvi patients , improved daily activities , independence 
 levels and thus significantly decreased depression levels when baseline and final bdi 
 results were compared in the study group .
therefore , regular and long - term use of cs will 
 improve well being of cvi patients .
this study was aimed to assess short - term effects of cs use in cvi patients .
although these 
 patients should have been followed up for longer term , long - term monitoring was not possible 
 due to transportation difficulties , family reasons , and financial problems .
nevertheless , we 
 contacted the patients from control group and educated them about the short - term benefits of 
 cs use . due to risk of development of venous ulcers in the advanced stages of cvi
, the regular use 
 of stocking starting from the early stages is recommended to prevent occurrence of cvi 
 symptoms .
further studies are necessary to evaluate the effect of cs use by cvi patients in 
 turkish economy and financial burden on cvi individuals in turkey . based on the findings of 
 this study ,
if the patients could be convinced to use cs for short - term duration , the 
 favourable effects will promote long - term use .
 [ purpose ] this study was aimed to analyse the effects of short - term use of compression 
 stockings ( cs ) on symptoms and qol in patients with chronic venous insufficiency ( cvi ) . 
 
 [ subjects and methods ] based on the ceap classification c2 and c3 , 117 patients with cvi 
 were enrolled in this study . 
 the participants were divided into two groups . 
 the control 
 group refused to use cs , however , was advised to do exercises and take skin care whereas 
 the cs group used cs and performed exercise . 
 the data were collected by using nottingham 
 health profile ( nhp ) , venous insufficiency epidemiological and economic study 
 ( veines - qol / sym ) and beck depression inventory ( bdi ) at baseline and after four weeks of 
 treatment and compared within and in between groups . [ results ] the comparison of pre- and 
 post - treatment differences between groups was statistically significant for all 
 parameters . in the study group , pre- and post - treatment scores for each parameter were 
 significantly different . however , elevated scores in the control group suggested worsening 
 of the illness . 
 [ conclusion ] this study established that short - term use of cs in patients 
 with cvi significantly improved disease specific and general qol by reducing venous 
 symptoms . 
 further studies with larger sample size are necessary to confirm these 
 findings . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION