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Assessing the influence of daily activities in the volumetry of inferior limbs by circumference measurement and water displacement volumetry
(Portuguese PDF version)

Cleusa Ema Quilici Belczak,¹ José Maria Pereira de Godoy,² Amélia Cristina Seidel,³ 3 Josy Anne Silva,⁴ Gildo Cavalheri Junior,5 Sergio Quilici Belczak6

1. Professor, Escola Superior Argentino-Americana de Flebologia e Linfologia, and Graduate Program in Lymphovenous Rehabilitation of the School of Medicine of São José do Rio Preto (FAMERP), SP, Brazil.
2. PhD. Adjunct professor, Department of Cardiology and Vascular Surgery, School of Medicine of São José do Rio Preto (FAMERP), SP, Brazil
3. PhD. Adjunct professor, Department of Angiology and Vascular Surgery, Department of Surgery, Universidade Estadual de Maringá (UEM), PR, Brazil.
4. Nurse. Responsible for the Centro Vascular de Maringá, PR, Brazil.
5. Physiotherapist. Graduate student, Graduate Program in Lyhmphedema Rehabilitation, School of Medicine of São José do Rio Preto (FAMERP), SP, Brazil
6. Medical student. Universidade Federal do Paraná (UFPR), Curitiba, PR, Brazil.

Correspondence:
Cleusa Ema Quilici Belczak
Centro Vascular
Av. Tiradentes, 1081
CEP 87013-260 - Maringá, PR, Brazil
E-mail: belczak@wnet.com.br

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ABSTRACT

Objective To demonstrate the influence of daily activities in the lower limbs volume by using water displacement volumetry and circumference measures.

Method: 28 subjects (56 limbs), 22 females and 6 males, ages varying from 16 to 64, without any evidence of venous disease and classified as C0 or C1 of CEAP, were recruited. All subjects were evaluated at different moments, at 8 am, before the beginning of daily activities, and at 6 pm, at the end of the working day. The methods were water displacement volumetry and tape measurement in the ankles and calf region.

Results: Volumetric measures of lower limbs and tape measurement of the right calf were statistically significant. Concerning the left leg, the average difference of calf tape measures, as well as both ankle areas, were not statistically significant.

Conclusion: We conclude that the daily activity may interfere in the volume of inferior limbs.

Key-words: lower extremity, physical activity, plethysmography.

J Vasc Br 2004;3(4):304-10

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The measurement of leg volume yields different type of data, such as the presence of edema resultant from chronic venous insufficiency (CVI), the efficacy of rehabilitation therapies and an early diagnosis of lymphedema - even before the onset of clinical signs.^1-3

Various techniques and methods have been used to assess leg volume precisely.¹ During the last decade there has been an increasing interest in the assessment and treatment of venous diseases, which lack objective, accurate and easily performable tests.

Usually, diagnoses are based exclusively on observation of the venous function, but it is well known that there are changes in venous hemodynamics during the day, and findings would depend on the moment the patient is analysed.⁴

Edema is an early sign of CVI1 and techniques used to assess it usually consist of determining leg and/or lower limb circumference (perimeter) or volume.⁵ The leg circumference measurement has two drawbacks: it does not include the foot in the volume measure, therefore providing only an approximate volume of the affected limb; and it needs the aid of a computer to perform sophisticated mathematical calculus.⁶

Water displacement volumetry, also named water plethysmography, was firstly introduced by Glisson, in 1622.⁷ This is a simple, cheap, safe, reproducible, and non-invasive method that can be performed by paramedics.⁶ However, an adequate room and water tanks are needed,¹ besides, it is a time-consuming procedure⁸ and cannot be performed in patients with active ulcer.⁹

This study was designed to evaluate changes in the leg volume of CVI-symptoms-free patients assessed by water plethysmography and circumference measurement after an entire day of activities.

PATIENTS AND METHOD

Patients had their ankle and calf circumference measurement assessed with a tape measure and were submitted to water plethysmography of the entire leg. From November 3 to December 18, 2003 (45 days), 28 subjects were selected at random (56 limbs), 22 women and 6 men, age range between 16 and 64 years old, with no previous history of venous disease and classified as C0 and C1 of CEAP.^10-12

All participants signed and informed consent before participating in the study and were assessed clinically before undergoing water plethysmography. The procedure was always performed by the same professional at room temperature (22 to 25 ºC) and at two different moments, at 8 am, before everyday labor activities started, and at 6 pm, when they had finished. All patients remained in the standing position at least for four hours a day, and they did not wear elastic stockings, as well as anti-hypertensive, diuretic or other drugs that could retain water in the body. Evidence of significant arterial insufficiency, reflux and/or occlusion of the deep and superficial venous systems was considered exclusion criteria. They were confirmed by eco-Doppler performed by a vascular ultrasonographer. Patients with diabetes mellitus, arterial hypertension, congestive heart failure, renal insufficiency and/or lymphedema were also excluded from the study.

The seven patients with no increase in the evening volume were submitted to the same tests in the day after, and almost the same data were obtained again.

The water recipients had two output orifices, one to level the water and the other to allow the displaced water to flow out of the recipient. The volume of liquid that corresponds to the distance between the two holes was previously measured. The water tanks were chosen according to the height of the anterior tibial prominence of the patient's leg (water level) (see Figure 1). The volume displaced when the limb was immersed and the volume that flows out of the tank into the gauged test tube (ml) should be equivalent to the limb volume. ^2,13

Figure 1 - Water plethysmography.

 

The higher calf and ankle were stained at 11 cm below the inferior portion of the patella, and at the maleolar prominence, respectively, so that circumference measurement taken in the morning could be taken at the same place in the evening.

The paired t test was used for statistical analysis accepting an alpha error of 0.05.

RESULTS

A statistically significant mean increase was evidenced after water displacement volumetry, as shown in Tables 1 and 2 and Figures 2, 3 and 4. Circumference measurement increased in the calf region of the right lower limb and was normal in the ankle (see Tables 3, 4 and 5).

Table 1 - Descriptive statistical analysis of volumetry measures (ml) at two different moments

Period	Limb	Mean	Mean standard deviation	Minimal volumetry	Maximal volumetry
Morning	Right	3,371.8	87.1	2,360	4,400
	Left	3,345.4	88.1	2,200	4,390
Evening	Right	3,454.3	90.8	2,365	4,570
	Left	3,405.7	90.4	2,320	4,460

Table 2 - Statistical analysis of differences in the volumetric measures

Limb	Means difference	Standard error of means difference	Standard deviations of differences standard	95% CI lower limit	95% CI upper limit	P
Right	82.5	11.7	61.9	58.4	106.5	< 0.001*
Left	60.3	13.5	71.8	32.4	88.5	< 0.001*

CI = confidence interval

Figure 2 - Mean volume: right and left lower limb.

Figure 3 - Volumetry of right lower limb.

Figure 4 - Volumetry of left lower limb.

Table 3 - Descriptive statistics of circumference measurements (cm) at two different moments

Region	Period	Limb	Mean	Mean Standard error	Minimal circumference	Maximal circumference
Calf	Morning	Right	35.7	0.6	29.5	41.5
		Left	35.5	0.6	29.3	42
	Evening	Right	36	0.6	29	42.5
		Left	35.6	0.6	29	42
Ankle	Morning	Right	22.9	0.4	19.5	26.5
		Left	22.9	0.4	20	27
	Evening	Right	23.1	0.4	20	26.9
		Left	23	0.4	20	27.3

Table 4 - Statistical analysis of differences in the circumference measurements in the calf region

				CI 95%
Limb	Differences	Mean difference	Standard error of mean difference	Lower limit	Upper limit	P
	Evening-
Right	morning	0.328	0.131	0.058	0.597	0.019 *
Left	Evening-	0.131	0.126	-0.127	0.389	0.308
	morning

CI = confidence interval

Table 5 - Statistical analysis of ankle region measurement differences

				CI 95%
Limb	Differences	Mean difference	Standard error of mean difference	Lower limit	Upper limit	P
	Evening-
Right	morning	0.183	0.120	-0.062	0.428	0.138
Left	Evening-	0.048	0.128	-0.215	0.311	0.710
	morning

CI = confidence interval

DISCUSSION

In accordance with the literature, our tests evidenced that circumference measurement is not always correlated with leg volume measurement.¹ As for the difference between the right lower limb (RLL) and left lower limb (LLL) concerning the calf measurement found in the present study, we infer that tape measurement is less precise than volumetry, but we are aware that a higher number of individuals would be necessary to confirm if there would be statistically significant differences in right and left calves during the morning and evening measurements. As for the water displacement volumetry, also named "Greek water plethysmography"² (plethysmo = volume and graphos = to write),¹⁶ findings seem to be more precise as results are one single value.¹⁴ The water displacement volumetry is a very ancient procedure which is still today acknowledged by some authors as the gold standard measurement, for including the entire lower extremity.^1,6 Some say it is 100% safe for the accurate assessment of limb volume and for estimating this changes according do pre-set factors.¹⁵

It has been recently known that noninvasive methods for the assessment of venous pathology were standardized disregarding the fact that results may be significantly affected by the moment when assessment is proceeded or by the activities patients may have performed before it. A competent system of valves is the key for a normal venous function and it has been reported that changes in venous hemodynamics during daily activities may be resultant from dysfunctions in this system.¹⁷

The total of the lower limb volume is composed of three parts: tissues, which do not change their volume significantly; blood volume, in which the venous volume (VV) changes quite significantly, and edema, which can be more or less pronounced.¹³

The importance of understanding changes in normal venous hemodynamics with daily activity is intuitively evident. The hemodynamics provides the diagnose, the disease severity level and data to monitor the therapy. Katz et al.⁴ evaluated changes in venous hemodynamics that occur in normal, symptom-free male and female volunteers, as a consequence of daily activity. They concluded that changes occur normally as a result from valvular dysfunction and that this fact can alter diagnostic conclusions in 20% of otherwise normal patients. Moreover, they say that these findings have important implications for an accurate patient evaluation, but extrapolation of these data to patients with established venous disease should not be made. These authors conclude that despite changes in the venous function are resultant from daily activity effects on the venous valves, they may be a consequence of other local or systemic effects, such as alterations in the vasomotor tonus, which affects venous hemodynamics. Changes in the VV were not found in their study and the correlation coefficient was low for the residual volume fraction (RVF), assessed by air plethysmography (APG) and justified by the strength with which the patient performed the test.

In a study by Bishara et al.,¹⁷ venous capacitance (ml), measured by impedance plethysmography, was significantly smaller in the evening than in the morning. The difference may be due to the fact that lower extremity veins are filled with an increased volume of blood after a long period in the upright position, either walking or standing. One should remind that widening of veins causes the valve cusps to separate, damaging their performance. Venous refilling time (VRT) was shorter in the evening than in the morning. VRT is firstly determined by the competence of venous valves, decreasing when they are insufficient, because of the rapid venous reflux. It is also affected by the arterial inflow, increasing in the presence of lower extremity ischemia.

Vayssairat et al.,¹⁸ in a study with symptom-free subjects and patients with varicose veins, observed that asymptomatic limbs did show differences in measurements performed in the morning and in the evening. This fact evidenced that the venous function of normal extremities is affected with daily activities.

According to Enrici & Caldevilla,¹⁹ edema is a direct consequence of venous hypertension, not only of changes in the valvular function but also of failure of the musculovenous pump or the so called impulse-aspirative pumps of the lower limbs.²¹ People's everyday life has imposed a sedentary lifestyle and this leads to a decrease in articular and muscular functioning, easing the venous stasis and consequently generating an increase in the volume of lower limbs during daily activities.

This increase may be resultant from interstitial edema or internal dilation of vessels. The findings of the present study were in accordance with those by Katz et al.,⁴ Bishara et al.,¹⁷ and Vayassairat et al.¹⁸ but besides the hypotheses suggested by these authors, the interference of the gravitational pressure on filtering and reabsorption of fluids by tissues should be considered, as it is an incontestable source of venous and lymphatic diseases. The present study found an increase in limb volume in the evening. Bishara et al.¹⁷ and Katz et al.⁴ suggest that these alterations are due to valvular dysfunction. Our viewpoint is that, even if this may be true, valvular dysfunction also contributes to an increase in the venous pressure and, therefore, to problems in the reabsorption of interstitial fluids. The hypothesis by Bishara et al.¹⁷ about the association of venous dilation with increased fluid volume is pertinent, however, it also represents an increase in the venous pressure and reabsorption problems. Summing up, both hypotheses may lead to an increase in the venous pressure. It is well known that edemas are worsened by varices, which are also responsible for venous hypertension.

When gravitational pressure decreases, the limb returns to the normal size, thus, the major factor is the damaging interference of this pressure on the lymph and venous drainage. Consequences are felt all over the system's microcirculation, as the lymphatic and venous reabsorption is affected. Therefore, the excess of exposure to gravitational pressure have a major role in volumetric changes during daily activities. The human body response may vary, affecting the vessels walls integrity and the capacity of maintaining normal blood volume in different degrees. The organism can be affected by structural changes in the vessels walls and local controls that yield more or less vessels dilation which, as a consequence, may compromise the valves. Another aspect that should be considered is the capillary permeability because it may cause significant alterations in the volume of limbs, especially when submitted to the gravitation action. These are changes that must be taken into account during the volumetric assessment of lower limbs.

Vessels are submitted to the degenerating force of gravitational pressure and they would respond to it depending on their integrity both with relation to diameter and walls constitution, which will yield more or less vessels enlargement. This fact may interfere in the valvular function and, consequently, contribute to an increase of the venous pressure.

In practical terms, the increase in the leg volume after daily activities may cause heaviness of limbs, fatigue and other symptoms that should be identified before being managed.

CONCLUSION

We conclude that daily activities may interfere in the volume of limbs and that their physiopahtological aspects should be identified before management.

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