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Varicose Veins: Addressing Occupational Risks for Healthcare Workers

It has been argued that nursing personnel do not have a higher rate of varicose veins than the general United States population. Varicose veins have an indeterminate etiology; it is not really known why certain people get them or whether the type/mode of work, such as nursing, exacerbates the condition. It appears that a common belief is that the physical nature of nursing is an attributing factor to the high incidence, but the jury is still out when it comes to scientific proof. Nurses often report in job appraisals and reviews that they notice the signs of varicose veins after only a few years of nursing training. This is a worrying prospect indeed, as training is minimal compared to the length of time people are now working to their retirement age.

Varicose vein can be an occupational hazard for healthcare workers, a predominantly female workforce. There are many tasks within the day of a nurse that are deemed to be contributory factors, such as standing, walking, lifting or carrying, and prolonged periods of sitting or standing. There is some evidence to suggest that workers who stand or walk significantly during their jobs have a higher rate of severity than those who do not. As per Census 2000 data, 94% of nurses are female. Although a higher incidence of varicose veins is found in women, the nature of nursing work appears to independently increase the risk in both male and female nursing personnel.

Causes and Symptoms of Varicose Veins

Other factors that can cause varicose veins include obesity, leg trauma, and aging. All of these factors can cause structural damage to the veins and lead to valve incompetence.

Intra-abdominal pressure from other conditions such as chronic liver disease or abdominal tumors can also lead to the development of varicose veins. Alterations of blood volume and pressure are the main cause of varicose veins occurring in these conditions. This is also the case for people with occupations that require them to stand for long periods of time. High vertical pressure on the lower extremities increases the likelihood of developing varicose veins. This may also be true for people with occupations that require prolonged sitting, as this position can also cause an increase in pressure to the vein.

Women are also more likely to develop varicose veins, likely due to hormonal factors and because they are subject to hormonal changes during pregnancy, premenstruation, and menopause. These changes may be a contributing factor to varicose veins in women, but the primary cause is the result of increased intra-abdominal pressure during pregnancy, which puts added stress on leg veins. This pressure can lead to varicose veins and even spider veins during pregnancy.

One-way valve incompetence can be the result of several factors. The most common cause of varicose veins is a hereditary predisposition. Studies have shown that 70% of patients with varicose veins have a family history of the disorder. In this case, the one-way valve incompetence is an inherited genetic defect. The defect may be in the actual valve or in the vein wall, but results in an insufficient functioning of the one-way valves that are necessary for efficient venous return to the heart.

Varicose veins are caused by too much pressure on the “one-way” valves within the veins. Due to this extra pressure, the valves become incompetent and allow blood to flow backwards and pool in the vein. This causes the vein to become ‘varicose’ and leads to the development of visible, and sometimes painful symptoms.

Occupational Risks for Healthcare Workers

According to recent studies, teachers and nurses have the highest incidence of varicose veins. This is because they typically sit and stand excessively for long hours. The overall prevalence rate for nurses is around 20-30%. Varicose veins in nurses were most frequently reported by those over 40 years of age. When compared with rates of the same age group in the general population, nurses were at a significantly increased risk. The presence of occupational venous disease among healthcare workers is problematic and cost-inefficient for the occupational workforce.

Venous disease has become a common health issue for many people. While a lot of that can be attributed to the natural aging process, changes in lifestyle, and genetic disposition, there are certain activities and occupations that can contribute to the risk of developing varicose veins or chronic venous insufficiency. Healthcare workers are at the greatest risk for developing these work-related problems. During a normal workday, a healthcare worker is on their feet a majority of the time and is required to stand in one spot, walk, or even run in emergency situations.

Prolonged Standing and Walking

A study by Foss et al utilized data from a nurse’s health study cohort to determine the relative risk of varicose vein surgery in relation to prolonged standing. After controlling for potential risk factors for varicose vein surgery, the odds of nurses having vein surgery were calculated to be 2.2 times greater for those nurses that worked an extended number of hours standing or walking in comparison to those that worked fewer hours. The duration of work standing or walking holding the greatest increased risk was shift work on the night shift. This study was one of the first to show a concrete association between an occupational risk factor and varicose veins and CVI. A limitation of this study was the failure to differentiate between standing and walking, although the duration of work standing or walking was shown to have the greatest effect on risk, with night shift work indicating that standing may have a greater effect than walking. Other healthcare workers have also noted effects of prolonged standing on the risk of varicose veins, but studies specific to various healthcare occupations and varicose veins are lacking. With such a high prevalence of CVI and varicose veins among the general population, it would be beneficial to determine if the increased risk related to prolonged standing will produce a significant increase in varicose vein prevalence in workers or specific healthcare worker groups.

Prolonged standing has been identified as an occupational risk factor for various health conditions and injuries among workers. This risk was first realized in the military and industrial sectors, and research has since trickled into the healthcare sector. An assumption that the benefits of standing far outweigh those of sitting has led to a lack of focus on detrimental effects of prolonged standing, and as a result, various workers have developed chronic venous insufficiency (CVI) and varicose veins.

Patients and care providers alike would be appalled by the significant gap in knowledge related to occupational risks of healthcare workers in comparison to the wealth of knowledge of occupationally related risks of workers in various other industries. Limited knowledge among healthcare workers about risks of activities and tasks associated with their occupation has resulted in a lack of prevention efforts and subsequent poor clinical outcomes. This lack of focus on prevention has perpetuated the notion that occupational injuries are unavoidable among healthcare workers. An enormous limitation in current research involves predominantly nurse-centered studies. Nurses comprise the largest sector of the healthcare workforce and are often categorized with other healthcare workers despite tasks and risk factors that may differ considerably. This generalization makes it difficult to determine specific task-related injury rates and risks among the myriad of healthcare occupations. This also leaves a gap in knowledge related to the risk of tasks shared among healthcare worker occupations, which is essential in developing preventative strategies and interventions. Because of the generalizations made about healthcare workers and lack of information about occupational risk factors, this paper will highlight varicose veins as an occupational risk to healthcare workers.

Heavy Lifting and Physical Strain

The most physically demanding tasks in healthcare professions involve lifting and moving patients. Varicose veins may be frequently seen in staff who transfer patients or lift heavy loads. If not performed correctly, heavy lifting, such as transferring a patient from bed to stretcher, can cause rectal or vaginal wall hernias from the increased intra-abdominal pressure. A case-control study in Taiwan also found an association between heavy physical work and development of varicose veins. It is known that continued heavy lifting can lead to chronic venous insufficiency. Smith and his colleagues surveyed 1329 female nurses (aged 30-55 years) from two large teaching hospitals. The group as a whole had a slightly higher relative risk of 1.36 for development of varicose veins over a 4-year period. Nurses aides had a relative risk of 2.31, while the risk for LPNs was 1.47. Though RNs only had a relative risk of 1.22, their risk was due entirely to those who lifted or moved patients on a regular basis. This study shows that not only the elderly population, but also relatively younger individuals with high occupational physical demands are at risk for development of varicose veins.

Exposure to Chemicals and Radiation

Healthcare workers face a wide variety of occupational health risks. Those who practice invasive procedures may be at risk for chemical or radiation exposure. Exposure to chemotherapeutic agents and antineoplastic drugs is of primary concern to those administering the medicines and those cleaning up spills. These drugs have been associated with risks to both the patient and the healthcare provider. Antineoplastic drugs have been implicated in adverse reproductive outcomes such as spontaneous abortion, congenital malformations, and various forms of cancer. The primary source of exposure is through dermal contact with contaminated surfaces or handling of the drugs during preparation and administration. Studies have shown that chemotherapy drugs may contaminate the gloves and gowns of those administering the drugs, and that exposure to drug contamination on surfaces is strong. Although exposure to these drugs generally occurs in the acute hospital setting, they are also used in the outpatient setting and in private homes, thereby posing a risk to healthcare workers in those environments. Other studies of nurses have shown that occupational exposure to antineoplastic drugs can be detected by monitoring urine specimens for biological indicators of DNA damage. Unfortunately, there is no consensus among healthcare researchers on safe levels of cytotoxic drugs, and the adoption of USP guidelines in work practice and engineering practice control measures is minimal.

Prevention and Management Strategies

Ergonomics has been identified as an occupation-specific risk factor. Work involving combinations of standing and sitting or prolonged standing, such as theatre or clinic work, is associated with a higher prevalence of varicose veins. For many healthcare workers, advice on changing posture and activity at work to limit veins from getting worse may seem impractical and ideologically clash with professional commitments. Nevertheless, proper use of ergonomics can be implemented to make activity less risky. The management and prevention of exacerbation of varicose veins for a healthcare worker involving changes of job or tasks is likely to be an individual exercise in unraveling the clinical epidemiology of varicose vein cause and effect.

Regular exercise is a key component in methods to prevent veins from getting worse. The muscle pump helps return flow in the veins, and the increased shear forces associated with muscle activity cause beneficial changes in the endothelium of the vein. This is particularly relevant to people who have mainly been drawn into more sitting or standing occupations from jobs which were previously more active. Exercises for the feet will also benefit healthcare workers who find themselves standing for long periods. Rotation of the foot helps to pump blood out of the leg. Hopping from toe to toe helps the calf muscle pump. Maintenance of a healthy lifestyle and weight are rather vague recommendations in UK guidance. In the occupational field, they are of course relevant when trying to select and retain people in employment.

Prevention and management strategies are highly beneficial in limiting the progression of varicose veins. It is particularly important for healthcare workers, many of whom already have developed the condition, to limit further deterioration. Decompensation of varicose veins can lead to swollen ankles and more severe problems with veins. Varicose eczema is common and is due to the skin becoming stained by iron and the leakage of small amounts of fluid through the skin from the vein. More severe complications include phlebitis and venous ulcers. Treatment for these conditions would be outside the scope of this discussion of occupational health problems and relies on the availability of referral to specialist vein units. The ideal is to prevent these difficult complications.

Regular Exercise and Physical Activity

An alternative would be to wear compression stockings during the exercise period to enhance the effectiveness and reduce symptoms of varicose veins. Overall, an active lifestyle will improve general health and strength while reducing the risk of varicose veins.

Regular exercise targeting the calf muscles will improve muscle tone and increase the amount of blood pumped back to the heart, decreasing the likelihood of varicose veins. Activities that involve constant force on the legs, such as weightlifting, are not ideal as they can increase venous pressure. However, good forms of exercise include walking and running, which use the calf muscles and improve overall cardiovascular health. Swimming is also highly recommended as it is low impact and the hydrostatic pressure of the water reduces peripheral pooling in the veins. These activities should be done for 30 minutes a day, 5 times a week for maximum effectiveness.

Regular exercise and physical activity play a significant role in the prevention and management of varicose veins for healthcare workers. In depth, healthcare is a physically demanding job with extended periods of standing and shifts that average between 8-12 hours. Nurses and physicians are at increased risk due to the long hours of standing involved in their jobs. Studies have shown that prolonged standing and sitting can lead to decreased strength and endurance of the leg muscles. This, in turn, can be detrimental for vein circulation in the legs. The calf muscles act as a second heart to push deoxygenated blood back up to the heart. Weak calf muscles can’t support this action and can lead to pooling and venous distention in the lower extremities.

Proper Body Mechanics and Ergonomics

A study assessing the effects of a program designed to change the habits of healthcare workers revealed the potential benefits of even small habit modifications. An assessment was carried out at a general hospital in Hong Kong, with five male and 31 female registered nurses who frequently experienced leg pain and fatigue due to prolonged standing periods. The mean age of subjects was 39.5 years. A three-month prospective substudy involving a selected group of 10 nurses revealed an increased compliance to wearing the stockings at 80% or more shifts at month 2 and 3 with fewer motivation sessions. All quality of life measures returned non-significant results. At three months, the setting was changed for all workers to a more expensive brand of stockings and another three-month assessment was carried out. This study concluded that stockings led to sustained decrease in leg symptoms and improved general health compared to baseline measures. A cumulative recurrence of leg symptoms was found with the use of stockings at less than 80% of workdays and improvement was significantly associated with an increased compliance to wearing the stockings. Wearing the stockings for greater than 80% of workdays was sufficient to maintain good general health and quality of life measures. The cessation of wearing the stockings led to sustained decrease in general health. This study may be limited in its generalizability and to nurses who work in environments similar to that of Hong Kong. However, the overall health benefits were remarkable and purchasing an expensive brand of stockings may further enhance the benefits.

Proper body mechanics, such as bending at the knees when lifting objects, can be useful in preventing the development of varicose veins. Recommendations for lifting suggest that the maximum weight facing an average male may cause injury is 25 kg, but most adults begin to incur spinal disc damage at a much lower weight. Non-weight bearing exercise to strengthen the abdominals and pelvic floor muscles, such as Pilates, can prevent the increase in intra-abdominal pressure pushing on the veins. This form of exercise is also beneficial in toning the muscles in the legs. Exercises to avoid include those that cause the individual to remain in a static position for prolonged periods, such as weight-lifting or cycling. Static positions enhance the effects of gravitational forces. If prolonged standing is unavoidable, it is beneficial to practice standing on tip-toe and then on the heels to reverse the effects of gravitational forces on the lower limbs.

Wearing Compression Stockings

Prolonged standing and sitting is a risk factor for varicose veins. Hence, anything that helps to prevent blood from pooling in the legs is a plus factor. The “coming of age” of elasticized gradient compression hosiery has not gone unnoticed by the research community. Many are investigating its effectiveness in occupational settings. Compression stockings are tighter at the ankles and become gradually looser as they go up the legs. This produces a gentle squeezing action on the leg, which helps to prevent leg swelling and the formation of varicose veins. The compression is measured in millimeters of mercury (mmHg). Although it is early days, there are some indications, especially from the more severe end of the spectrum, that symptoms are reduced and the rate of progression slowed. This is only part of the story. One has to consider compliance with their use, both in the short and long term, and willingness to wear them depends largely upon subjective acceptance of the product. A dirt cheap, easily implemented intervention may also prove to be an important positive measure that can be taken. This can involve education regarding leg health and simple provision of taking the weight off the feet. The author suggests that health education could be a powerful tool in the fight against occupational-related varicose veins. Without intention, jobs that require long periods of static standing are risking the health of their workers through the provocation of varicose veins. Skewing the cost-benefit analysis with an argument that it is far more cost-effective to prevent this condition than to treat it, easy measures could be implemented to prevent blood pooling in the legs and thus the onset of varicose veins.

Taking Breaks and Resting Legs

Exercises are valuable in improving venous return. Any form of exercise using the calf muscle is good. An example is walking, which is the simplest of all leg exercises. It has been shown that a daily 30-minute walk is beneficial in improving vein health. Contracting the calf muscles repeatedly while sitting is a good exercise for the muscles and veins. However, it is best to avoid heavy impact exercise and prolonged standing as these can have adverse effects on the veins. Static standing is particularly tiring for the legs and has only a minimal effect on venous return.

Taking regular breaks during long hours of standing and sitting will help in preventing varicose veins and will reduce the risk of developing chronic venous insufficiency. Elevating the legs at the end of a long day is helpful to improve venous return. However, the most effective way of resting the legs and improving venous return is to wear gradient compression stockings and sit or sleep with the legs elevated above the level of the heart. This has been shown in several studies.

Maintaining a Healthy Lifestyle

A healthy diet, similar to exercise and physical activity, is important in the prevention of varicose veins. Obesity is a significant risk factor for the development of varicose veins, as it can increase the pressure within the leg veins. Increased pressure within the veins can cause the walls and valves within the veins to become weak and no longer function properly. This can lead to the development of varicose veins and, in more severe cases, other venous disorders such as chronic venous insufficiency. By maintaining a healthy diet and an ideal body weight, there is less pressure on the leg veins. This can help prevent the development of varicose veins and venous insufficiency.

First and foremost, in order to maintain a healthy lifestyle, it is important to quit smoking. Smoking has been established as a risk factor in the development of varicose veins multiple times. Smoking causes vasoconstriction (tightening of the blood vessels), which can lead to increased blood pressure in the leg veins. Increased blood pressure within the veins can lead to the development of varicose veins or the worsening of the varicose veins that are already present. Smoking also decreases the amount of oxygen in the blood and can weaken and damage the valves within the veins. These are all reasons which make it important for any individual, not only those in healthcare, to quit smoking for prevention of varicose veins and other venous disorders.

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