Aquatic Versus Land-Based Exercise in Women With Lipedema

Lipedema is a chronic, underrecognized condition primarily affecting women, characterized by a bilateral and symmetrical expansion of subcutaneous fat and connective tissue in the limbs-most commonly the hips, thighs, and lower legs-while sparing the hands and feet. Frequently misdiagnosed as standard obesity, lymphedema, or venous insufficiency due to overlapping symptoms, it lacks a specific biomarker, requiring diagnosis via clinical history, physical exam, and exclusion of differential conditions.

Unlike typical obesity, lipedema-related limb enlargement is accompanied by distinct symptoms:

Physical Discomfort: Spontaneous or pressure-induced pain, tenderness, persistent heaviness, easy bruising, and nodular or fibrotic tissue changes.

Functional Decline: Worsening symptoms from standing or inactivity, leading to reduced quadriceps strength, diminished walking capacity, and functional impairment beyond what is explained by body mass alone.

Psychosocial Impact: High rate of emotional distress, poor body image, and reduced quality of life driven by pain, diagnostic delays, and societal stigma.

Underlying Mechanisms: Though incompletely understood, proposed factors include adipocyte hypertrophy, tissue fibrosis, microvascular fragility, chronic inflammation, and altered fluid regulation. Because swelling changes do not inherently reflect lymphatic transport, direct imaging is required to verify lymphatic mechanisms.

Inclusion criteria

• Women diagnosed with lipedema for at least five years
• Had stage 2 or 3 and type 2 or 3 disease
• Had a body mass index of ≥25 and <40 kg/m²
• Able to walk independently, with or without their usual assistive device
• Had received medical clearance to participate in moderate-intensity aquatic and land-based exercise
• Able to understand the study procedures and provide written informed consent.

Exclusion criteria

• Had clinically significant lymphedema, uncontrolled chronic venous insufficiency, acute thrombosis, or another major cause of lower-limb edema
• Had open wounds, active skin infection, fever, or another infectious condition incompatible with pool use
• Had uncontrolled cardiovascular, metabolic, respiratory, or neurological disorder that could compromise exercise safety; a cardiac pacemaker or congestive heart failure; pregnancy; active cancer or ongoing chemotherapy, immunotherapy, or radiotherapy
• Had history of bariatric surgery, recent major surgery, or liposuction; current use of weight-loss medication
• Had current participation in structured aquatic or lower-limb exercise exceeding the protocol-defined threshold; or severe fear of water or inability to enter and exit the pool safely.