Medicina (Kaunas). 2025 Jan 27;61(2):231. doi: 10.3390/medicina61020231.

ABSTRACT

Lymphedema is a chronic condition characterized by the accumulation of lymphatic fluid in the tissues, causing swelling primarily in the limbs, though other body parts can also be affected. It commonly develops after lymph node removal, or radiation therapy, or due to congenital lymphatic system defects. Effective management is essential due to its significant impact on physical function and quality of life. Complete Decongestive Therapy (CDT) is the primary treatment for lymphedema. This comprehensive approach combines manual lymphatic drainage (MLD), compression bandaging, skincare, and exercise. An early diagnosis and initiation of CDT are critical to preventing irreversible damage to the lymphatic system and worsening symptoms. Successful outcomes depend on timely treatment, patient adherence, and the consistent use of all CDT components, with compression therapy and exercise playing particularly vital roles. Recent research highlights how skin and fat tissue characteristics, such as increased skin thickness and adipose tissue accumulation, complicate lymphedema management, especially in advanced stages. In these cases, where fibrosis and fat deposition are more prominent, traditional CDT may need to be supplemented with advanced treatments like liposuction or enhanced compression techniques. This study explores the factors influencing the success of decongestive therapy, including the stage of lymphedema at the diagnosis, treatment protocols, and individual patient characteristics like skin and fat tissue properties.

PMID:40005348 | PMC:PMC11857323 | DOI:10.3390/medicina61020231

J Osteopath Med. 2025 Feb 12. doi: 10.1515/jom-2024-0122. Online ahead of print.

ABSTRACT

CONTEXT: Chronic rhinosinusitis (CRS) is a prevalent inflammatory disease of the paranasal sinuses that may significantly impair quality of life. CRS may also benefit from the application of manual techniques through osteopathic manipulative treatment (OMT), which aims to improve venous and lymphatic circulation, sympathetic and parasympathetic outflow, and cervicothoracic somatic dysfunction.

OBJECTIVES: This study aimed to assess whether OMT focused on lymphatic drainage of cranial structures can provide immediate, as well as sustained, relief of CRS symptoms.

METHODS: This prospective, single-blinded study (WCG IRB study number: 1359444) was conducted at an allergy/immunology practice. Study participants included 43 adult patients, with a diagnosis of CRS, refractory to conventional medical therapy, with prior exposure to OMT. Patients consented to the study and were assigned by the provider to the OMT group or the control group 50/50. A four-question, 5-point Likert scale survey inquiring about the severity of nasal congestion, postnasal drainage, and facial or sinus pain/pressure, as well as the appreciation of the opportunity for an alternative therapy, was administered prior to the intervention. An OMT sequence was applied by the same osteopathic physician to each OMT group participant in the following order: thoracicinlet release, venous sinus drainage, occipital-atlantal decompression, thoracic paraspinal inhibition, facial sinus pressure, and Galbreath technique. A structural examination involving light touch was applied to the control group participants. The same 5-point Likert scale survey was administered immediately after the intervention. Participants were provided a blank copy of the survey to save and complete 10 days after the intervention. A paired t-test was applied for statistical comparison between the pre- and postsurveys.

RESULTS: A total of 43 patients, including 22 patients in the treatment group (51.1 %) and 21 (48.8 %) patients in the control group, consented to and participated in the study, from May 1 to 30, 2024. Study demographics included 76.7 % females (n=33), 23.3 % males (n=10), 97.7 % White (n=42), and they patients had an average age of 54.4 years. Surveys administered before and immediately after the intervention were completed by 100 % of the study participants. All three surveys, including the presurvey and postsurvey completed immediately after and 10 days after the intervention, were completed by 60.5 % of the study participants. The OMT group pre-vs. immediate postsurvey results scored a statistically significant decrease in the severity of nasal congestion (p=0.001), postnasal drainage (p=0.002), and facial or sinus pain or pressure (p=0.0004).

CONCLUSIONS: Our single-blinded, prospective survey findings suggested that there was a benefit of OMT application for the immediate relief of CRS symptoms, predominantly in alleviating the severity of sinus pain or pressure. This study is the first large study (n=43) with a control group that shows that OMT techniques improve immediate CRS symptom relief of nasal congestion, postnasal drainage, and facial or sinus pain/pressure when compared to the pretreatment survey. Our study also demonstrated that the symptomatic relief by OMT of rhinosinusitis was not sustained in 10 days. OMT offers a safe, nonpharmacological complementary therapy to relieve lymphatic congestion and improve mucociliary clearance in CRS.

PMID:39932258 | DOI:10.1515/jom-2024-0122

2024 Jan 29. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–.

ABSTRACT

The lymphatic system can easily be overlooked but drastically impacts the immune system. This mesh of tissues and organs exports toxins, waste, and unnecessary materials out of the body via lymph fluid. Modern medical education today does not do full justice to the lymphatic system. This system removes fluids and protein from the extracellular space and interstitium to maintain proper osmotic balance. In acute inflammation, changes occur in the lymphatic system, so our body will try to maintain appropriate homeostasis.

Osteopathic manipulative treatment (OMT) is used to treat somatic dysfunctions. OMT focuses on enhancing the neuromuscular connection, improving biomechanical balance, decreasing pain, and increasing the range of motion. In the historical context of osteopathy, Dr. Andrew Taylor Still placed a lot of importance on the lymphatic system during his development of the tenets of osteopathy. In the book The Philosophy and Mechanical Principles of Osteopathy by Andrew Taylor Still, he mentions that “We suffer from two causes: want of supply and the burdens of dead deposits.” Dr. Still understood the importance of the lymphatic system’s role in clearing the “debris” that may cause disease. In modern medicine, we know more about the lymphatic vessels and how they may contribute to certain chronic conditions.

Inflammation is a normal homeostatic response to injury or infection; it is the body’s response to try to heal. During the process, significant amounts of different cytokines and other inflammatory mediators are released to signal the appropriate immune cells. Removing these markers through lymphatic drainage flow is essential to help resolve the inflammation.

Understanding the lymphatic formation and removal process from the interstitium is a crucial physiologic principle to treat osteopathically. Osteopaths believe that lymphatic drainage plays a significant role in rheumatoid arthritis; immune complexes are formed in the disease, which cause substantial inflammatory exudates. These exudates cause pain and destroy joint tissue, and it has been shown that there is increased lymph production and drainage from these patients.

Some osteopathic techniques are similar to those implemented by chiropractors, physical therapists, and massage therapists, and other methods are solely used by osteopathic physicians. However, one main difference is that these physicians are trained to apply these techniques with their extensive knowledge of physiology and anatomy. This allows osteopathic physicians to tailor their treatment to each patient. This will enable OMT to be applied to more than just spinal alignment to treat many physiologic conditions.

Some techniques were designed to be used to help increase lymphatic flow. Some other techniques were not designed to be lymphatic, but they can be used in its treatment by understanding the complexity of the human anatomy. When treating lymphatic techniques, it is essential to be mindful of structures that may impinge the lymphatic vessels, such as fascia, muscles, ligaments, and other somatic dysfunctions. Many techniques comprise OMT, which can treat many ailments, including the lymphatic system. Problems within this system lead to the accumulation of lymph, decreased immune responses, fat build-up, tissue swelling, and connective tissue accumulation.

PMID:32644477 | Bookshelf:NBK559051

2023 Feb 20. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–.

ABSTRACT

Lymphadenopathy, or adenopathy, is a common abnormal finding during the physical exam in general medical practice. Patients and physicians have varying degrees of associated anxiety with the finding of lymphadenopathy, as a small number of cases can be caused by neoplasms or infections of consequence, for example, HIV or tuberculosis. However, it is generally recognized that most localized and generalized lymphadenopathy is of benign, self-limited etiology. A clear understanding of lymph node function, location, description, and the etiologies of their enlargement is important in clinical decisions regarding which cases need rapid and aggressive workup and which need only be observed.

The lymph node functions as an antigen filter for the body’s reticuloendothelial system. It consists of a multi-layered sinus that sequentially exposes B-cell lymphocytes, T-cell lymphocytes, and macrophages to an afferent extracellular fluid. In this way, the immune system can recognize and react to foreign proteins and mount an immune response or sequester these proteins as appropriate. In this reaction, there is some multiplication of the responding resistant cell line; thus, the node increases in size. It is generally held that a node size is considered enlarged when it is more significant than 1 cm. However, the reality is that “normal” and “enlarged” criteria vary depending on the node’s location and the patient’s age. For example, children younger than 10 have more hypertrophic immune systems, and nodes up to 2 cm can be considered normal in some clinical situations. However, an epitrochlear node above 0.5 cm is deemed pathological in an adult.

The lymphadenopathy’s pattern, distribution, and quality can provide much clinical information in the diagnostic process. Lymphadenopathy occurs in 2 patterns: generalized and localized. Generalized lymphadenopathy entails lymphadenopathy in 2 or more non-contiguous locations. Localized adenopathy occurs in contiguous groupings of lymph nodes. Lymph nodes are distributed in discrete anatomical areas, and their enlargement reflects the lymphatic drainage of their location. The nodes may be tender or non-tender, fixed or mobile, discreet or “matted” together. Concomitant symptomatology and the epidemiology of the patient and the illness provide further diagnostic cues. A thorough history of prodromal illness, fever, chills, night sweats, weight loss, and localizing symptoms can be very revealing. Additionally, the demographic particulars of the patient, including age, gender, exposure to infectious disease, toxins, medications, and habits, may provide further cues.

As evidenced above, the critical step in evaluation for adenopathy is a careful history and focused physical exam. The patient’s clinical presentation determines the extent of the history and physical. For example, a patient with posterior cervical adenopathy, sore throat, and tremendous fatigue needs only a careful history, cursory examination, and a mono test. In contrast, a person with generalized lymphadenopathy and fatigue would require more extensive investigation. Generally, most lymphadenopathy is localized (some site a 3:1 ratio), with the majority represented in the head and neck region (again, some site a 3:1 ratio). It is also accepted that all generalized lymphadenopathy merits clinical evaluation, and the presence of “matted lymphadenopathy” strongly indicates significant pathology.Examination of the patient’s history, physical examination, and the demographic in which they fall can allow the patient to be placed into 1 of several different accepted algorithms for workup of lymphadenopathy. Using these cues and selecting the correct arm of the algorithm allows for a fairly rapid and cost-effective diagnosis of lymphadenopathy, including determining when it is safe to observe.

Algorithmic Analysis of Lymphadenopathy

After a history and physical examination are completed, lymphadenopathy is placed into 3 categories:

1. “Diagnostic” such as strep pharyngitis or upper respiratory tract disease, in which case the course of action is to treat the condition.

2. “Suggestive” such as mononucleosis lymphoma or HIV, wherein the history and physical strongly suggestive diagnosis-specific testing is performed, and if positive, the action is to treat the condition.

3. “Unexplained” where the lymphadenopathy is divided into generalized lymphadenopathy and localized lymphadenopathy.

For unexplained localized lymphadenopathy, a review of history, a regional exam, and epidemiological clues are used to separate patients into lower (no risk of malignancy or serious disease) versus higher risk for serious disease or malignancy categories. Suppose the patient is at no risk for malignancy or serious illness. In that case, the reasonable course is to observe the patient for 3 to 4 weeks to see if the lymphadenopathy resolves or improves. In this case, the clinician is safely cleared to follow the patient. If the lymphadenopathy does not resolve or improve, the next step is to obtain a biopsy. If the patient is judged to have a risk for malignancy or serious illness, the procedure is to proceed immediately to biopsy.

For unexplained generalized lymphadenopathy, the key to diagnosis is a history to evaluate for suspected causes. The initial search would be questioning for a mononucleosis-type syndrome evidenced by fever, atypical lymphocytosis, and malaise. Included in these differentials would be Epstein-Barr virus, cytomegalovirus, toxoplasmosis, and (especially in the case of a flu-like illness and her rash) the initial stages of an HIV infection. The second step in evaluating unexplained generalized lymphadenopathy involves carefully reviewing epidemiological cues. Included in the epidemiological cues would be:

1. Infectious disease exposure

2. Animal exposure

3. Insect bites

4. Recent travel

5. Complete medication history

6. Personal habits: smoking, consumption of alcohol, consumption of drugs- pay special attention to a history of IVTA, high-risk sexual behavior

7. Consumption of under-cooked food/untreated water

Although there is no “cookbook” for the laboratory evaluation of generalized unexplained lymphadenopathy, the initial steps are to obtain a complete blood count (CBC) with a manual differential and EBV serology. If non-diagnostic, the next steps would be PPD placement, RPR, chest x-ray, ANA, hepatitis B surface antigen, and HIV test (see Image. Mediastinal Adenopathy). Again, if any of the above are positive, appropriate treatment can be initiated. In the presence of negative serological examinations, radiological examinations, and or significant symptomology, a biopsy of the abnormal node is the gold standard for diagnosis.Statistics concerning lymphadenopathy are inaccurate as the great majority of lymphadenopathy is caused by a non-reportable illness and thus not reported or taken into account. This results in a statistical bias, or skew, toward the reportable causes of lymphadenopathy: malignancies, HIV, tuberculosis, and sexually transmitted infections. Citations in the recent literature for general medical practice indicate that less than 1% of people with lymphadenopathy have malignant disease, most often due to leukemia in younger children, Hodgkin disease in adolescence, non-Hodgkin disease, and chronic lymphocytic leukemia in adults. It has been reported the general prevalence of malignancy is 0.4% in patients under 40 years and around 4% in those older than 40 years of age seen in a primary care setting. It is reported that the prevalence rate of neoplastic disease rises to nearly 20% in referral centers and rises to 50% or more in patients with initial risk factors.

PMID:30020622 | Bookshelf:NBK513250

2022 Sep 19. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–.

ABSTRACT

Yellow nail syndrome (YNS) is a rare condition defined by the presence of 2 of the following 3 symptoms:

1. Slow-growing, hard, yellow, and dystrophic nails

2. Lymphedema

3. Respiratory tract disease

The earliest case of YNS was reported by Heller in 1927. However, in 1947, Samman and White published the first case series of YNS in patients with nail discoloration and lymphedema. Pulmonary disease, specifically pleural effusion, was added to the diagnostic criteria by Emerson in 1966. The syndrome generally affects adults aged 50 and older. However, case reports of YNS occur in children and even newborns. Anatomically, YNS affects the fingernails, toenails, the respiratory tract, and gravity-dependent areas that can accumulate fluid (typically lower extremities). These signs and symptoms are believed to be due to dysfunction in lymphatic drainage.

Nails

As the name suggests, xanthonychia (yellow nail coloration) is a common feature of YNS; however, yellow nails are not required if 2 of the other clinical signs are present. Discoloration varies from pale yellow to dark green; nails can be opaque or translucent. The manifestations are commonly misdiagnosed as onychomycosis (discoloration due to fungal infection), as the nails may become thickened, hard, and curved. A quick inspection of fingernails and toenails can help expand the differential for a patient with other vague complaints without additional expense.

Respiratory Tract

The respiratory tract is involved in more than half of patients with YNS. The most common manifestation is a chronic cough, followed by pleural effusion. In one of the largest reviews of patients with YNS, Valdés et al found nearly all effusions exudative with a lymphocytic predominance. Of the 66 subjects, approximately 70% of effusions were bilateral. Other pulmonary manifestations include bronchiectasis, recurrent pneumonia, sinusitis, and pulmonary fibrosis. Pulmonary function testing in YNS is typically unremarkable, and biopsies do not usually contribute to the diagnosis.

Lymphedema

Lymphedema typically manifests in the bilateral lower extremities and does not differ in appearance from primary lymphedema. Lymphedema occurs in 30% to 80% of patients. Dynamic lymphatic imaging (lymphoscintigraphy) does differ between patients with edema related to YNS and those with primary lymphedema. Edema can be pitting and can be easily confused with fluid accumulation, often seen in patients with decompensated congestive heart failure. This can be especially deceiving if patients present with concurrent pleural effusions. As in primary lymphedema, treatments often involve massage, compression dressing, exercises, and, less commonly, surgical interventions.

Natural History

The diagnosis of YNS can be difficult because patients rarely present concurrently with all 3 clinical criteria. Lymphedema is the initial symptom in approximately one-third of YNS diagnoses. The prognosis and disease course depend on the individual’s symptoms and the timing of diagnosis. In some mild cases, the symptoms of YNS can be resolved without intervention. Unfortunately, many symptoms recur despite treatment and require continuous care. YNS can negatively affect one’s quality of life, including cosmesis and worsening functional status. Recurring soft tissue infections (eg, cellulitis from severe lymphedema), pulmonary infections (pneumonia/empyema), and pulmonary effusions can lead to complications such as antibiotic resistance, pulmonary scarring, and protein loss.

PMID:32491692 | Bookshelf:NBK557760

Semin Oncol Nurs. 2025 Feb;41(1):151792. doi: 10.1016/j.soncn.2024.151792. Epub 2024 Dec 24.

ABSTRACT

OBJECTIVES: Information from indocyanine green (ICG) lymphography (ICG-L) can be used to guide an individual’s lymphedema therapy plan. However, the mechanisms for this clinical translation are not well described. This study proposes a novel clinical decision support tool for translating ICG-L findings into individualized lymphedema therapy plans and describes subsequent changes in plan features of manual lymphatic drainage and compression.

METHODS: This before-after study compared specific therapy plan features before and after ICG-L for participants with limb lymphedema. After participants had undergone ICG-L, the individuals’ ICG-L findings were translated into an ICG-L-informed therapy plan using a novel clinical decision support tool, ICG-TRANSLATE. A predetermined coding tree was used to identify changes in elements of manual lymphatic drainage and compression therapy plan recommendations.

RESULTS: Following the application of the ICG-TRANSLATE decision support tool, 100% (n = 25) of participants had a change in manual lymphatic drainage recommendations, including elements of terminal nodes, pathway, and technique. Additionally, 88% (n = 22) had a change in compression recommendations, which was most commonly a change in garment limb coverage.

CONCLUSIONS: ICG-L findings informed changes to traditional lymphedema therapy plan modalities of manual lymphatic drainage and compression. Whether this change to individual therapy recommendations translates into improved lymphedema outcomes requires further investigation.

IMPLICATIONS FOR NURSING PRACTICE: A clinical decision support tool may assist practitioners in translating ICG-L findings into individualized lymphedema therapy plans for people with lymphedema. Further exploration is necessary to determine if the management changes derived through ICG-L-informed therapy plans improve outcomes for people with lymphedema.

PMID:39721899 | DOI:10.1016/j.soncn.2024.151792

J Pak Med Assoc. 2024 Dec;74(12):2168-2170. doi: 10.47391/JPMA.11419.

ABSTRACT

The quasi-experimental study was conducted at the Allied Hospital, Faisalabad to investigate the effect of complex decongestive physical therapy on sensory testing in postmastectomy- related lymphoedema patients. The sample comprised 18 participants enrolled using convenience sampling technique. All the participants received complex decongestive physical therapy during 5 sessions per week for 3 weeks. The intervention comprised manual lymphatic drainage, multi-layered compression bandages, skin care and patient-oriented exercises for breast cancer-related lymphoedema. Upper limb circumference of the subjects was measured, while twopoint discrimination test, pressure pain threshold test and tactile localisation test were also conducted. Complex decongestive physical therapy showed a significant difference in pre- and post-intervention values (p<0.05). Complex decongestive physical therapy was found to be effective in improving sensory perceptions, like discrimination, tactile and pain pressure threshold, as well as oedema.

PMID:39658990 | DOI:10.47391/JPMA.11419

Cureus. 2024 Nov 5;16(11):e73053. doi: 10.7759/cureus.73053. eCollection 2024 Nov.

ABSTRACT

Lymphedema, characterized by impaired lymphatic drainage, presents in primary and secondary forms, causing limb enlargement and other complications. Management involves a multidisciplinary approach, with manual lymphatic drainage and surgery as key interventions. Treatment aims to improve quality of life, with surgical debulking showing positive outcomes, as demonstrated in a case of severe lower limb lymphedema. A 40-year-old male with severe congenital lymphedema praecox presented with left lower extremity swelling and cellulitis. Despite previous unsuccessful surgery, subsequent debulking surgeries over nine months improved function and appearance. Biopsies confirmed lymphedema praecox diagnosis. Lymphedema poses significant challenges, often requiring surgical intervention such as the Charles procedure, which involves surgically removing skin and soft tissue layers down to the deep fascia in the affected limb, with the excised skin repurposed as a graft for coverage, in severe cases. However, milder cases may go unnoticed, leading to delayed treatment. Our patient experienced advanced lymphedema, necessitating a staged surgical approach to minimize risks and enhance outcomes. This strategy successfully managed blood loss and improved cosmetic results, ultimately improving the patient’s quality of life. Lymphedema poses complex challenges, with tailored treatments such as staged procedures essential for optimal outcomes. Our case emphasizes the need for careful consideration and patient counseling, highlighting the value of strategic management approaches. By minimizing risks and optimizing outcomes, we aim to enhance the quality of life for individuals with lymphedema, underscoring our commitment to ongoing improvement in patient care.

PMID:39640155 | PMC:PMC11619476 | DOI:10.7759/cureus.73053

Asian Pac J Cancer Prev. 2024 Nov 1;25(11):3771-3779. doi: 10.31557/APJCP.2024.25.11.3771.

ABSTRACT

BACKGROUND: Post-mastectomy lymphedema is a common complication following breast cancer surgery, characterized by the accumulation of lymphatic fluid, causing swelling, discomfort, and functional limitations in the affected arm. Traditional treatments for lymphedema include manual lymphatic drainage and compression garments, but their effectiveness is variable, and many patients do not achieve satisfactory outcomes. Emerging therapeutic modalities such as Low-Level Laser Therapy (LLLT), Kinesio Taping, and Endermology offer potential non-invasive treatment alternatives. However, the relative efficacy of these approaches in reducing lymphedema, improving limb function, and enhancing quality of life in post-mastectomy patients remains unclear.

OBJECTIVE: This study aims to determine the effects of low-level laser therapy, kinesio taping, and endermology on breast cancer patients post-mastectomy with lymphedema.

METHODS: A systematic review and meta-analysis were conducted based on PRISMA guidelines. Searches were carried out in databases using keywords. Inclusion and exclusion criteria were applied to select the studies to be included. The selected studies were critically appraised using Cochrane’s critical appraisal tool. The chosen studies were extracted and analysed both qualitatively and quantitatively. Quantitative analysis was performed using both fixed-effects and random-effects approaches.

RESULTS: Eighteen studies were included in this analysis. All studies were randomized trials with good quality based on critical appraisal. The analysis found a significantly greater reduction in arm volume in the combined intervention group (MD = 76.27; 95% CI = 33.84-118.69) and in each therapy group: low-level laser therapy (MD = 91.98; 95% CI = 41.99-141.97) and endermology (MD = 34.61; 95% CI = 20.81-48.41). However, there were no significant differences in the reduction of arm circumference or pain scale, either overall or for each therapy individually.

CONCLUSION: Low-level laser therapy and endermology provide better outcomes for breast cancer patients with post-mastectomy lymphedema compared to conventional therapy.

PMID:39611899 | DOI:10.31557/APJCP.2024.25.11.3771

J Vasc Surg Venous Lymphat Disord. 2025 Mar;13(2):102005. doi: 10.1016/j.jvsv.2024.102005. Epub 2024 Nov 13.

ABSTRACT

OBJECTIVE: Demonstrate the effectiveness of complex decongestive therapy (CDT) in patients with chronic venous insufficiency (CVI).

METHODS: A single-blind randomized controlled trial was conducted, where the participants were patients with CVI (n = 21/42) were assigned randomly to an experimental group (n = 11/22) or a control group (n = 9/18). A treatment of CDT (manual lymphatic drainage, intermittent pneumatic presotherapy, bilayer bandage) was applied to the experimental group for 4 weeks 2 days per week and no treatment was applied to the control group. The patients were evaluated at baseline (t0), 1 week after finishing the intervention (t1), and 6 weeks after the intervention (t2). The effectiveness of the treatment on symptoms and quality of life (QoL) (heaviness, pain and Chronic Venous Insufficiency Quality of Life [CIVIQ-20] questionary), edema, venous flow, and impedanciometry measurements was evaluated.

RESULTS: An improvement in the patient’s QoL was observed: there was a decrease in symptoms such as heaviness and pain, an increase in the average velocity of the left femoral vein and left internal saphenous vein (ISV), a decrease in the ISV diameter in both extremities and a decrease in body mass index and fat mass in both extremities. These results were maintained when following up at 6 weeks, except for the improvement of QoL.

CONCLUSIONS: CDT treatment improves the CIVIQ-20 and Venous Clinical Severity Scores. It also improves symptoms (pain and heaviness), venous flow velocity (superficial veins and deep veins [common femoral vein, femoral vein, popliteal vein]) and decreases body mass index, fat mass, and ISV diameter.

PMID:39542398 | DOI:10.1016/j.jvsv.2024.102005