Aerobic Training in Lower Extremity Lymphedema

Lower extremity edema will be assessed using circumferential measurements obtained at 5-cm intervals from the medial malleolus to the inguinal region using a non-elastic measuring tape. Measurements will be performed in the supine position after a standardized rest period. The same evaluator will perform all measurements to ensure consistency. Mean limb circumference (cm) will be calculated to evaluate changes over time.

Walking speed, expressed in meters per second (m/s), will be assessed using calibrated two-dimensional spatiotemporal gait analysis with Kinovea motion analysis software. Calibration will be performed using a known reference distance prior to analysis. Participants will walk over a predetermined distance at a cadence standardized between 80-90 beats per minute using a metronome. Video recordings will be obtained from sagittal and frontal planes with reflective markers placed on predefined anatomical landmarks to improve measurement accuracy.

Step length, expressed in centimeters (cm), will be assessed using calibrated two-dimensional spatiotemporal gait analysis with Kinovea software under the standardized walking conditions described above.

Double support time, expressed as a percentage (%) of the gait cycle, will be assessed using calibrated two-dimensional spatiotemporal gait analysis with Kinovea software under standardized walking conditions.

Cadence, expressed in steps per minute (steps/min), will be assessed using calibrated two-dimensional spatiotemporal gait analysis with Kinovea software under standardized walking conditions.

Static postural control will be assessed using the Balance Error Scoring System (BESS). Participants will perform three stance conditions (double-leg stance, single-leg stance, and tandem stance) on a firm and foam surfaces. Each stance will be maintained for 20 seconds with eyes closed and hands placed on the iliac crests. Balance errors, including stepping, opening the eyes, lifting hands from the hips, stumbling, or remaining out of position for more than five seconds, will be recorded.

The total BESS score will be calculated by summing the number of errors across all stance conditions. The total score will be expressed as the number of errors, with lower scores indicating better postural control and higher scores indicating poorer postural control. BESS total score ranges from 0 to 60 errors, with higher scores indicating worse static postural control and lower scores indicating better postural control.

Dynamic postural control will be assessed using the Timed Up and Go (TUG) test, a valid and reliable measure of functional mobility and balance. Participants will be instructed to rise from a standard chair, walk a distance of 3 meters at a safe and comfortable pace, turn around, walk back to the chair, and sit down.

The time required to complete the task will be recorded in seconds (s) using a stopwatch. TUG performance will be expressed as completion time in seconds, with shorter times indicating better dynamic postural control and longer times indicating poorer performance.

Lower extremity muscle strength will be assessed using Manual Muscle Testing (MMT), a standardized clinical method for evaluating muscle strength. The following muscle groups will be evaluated bilaterally: hip flexors, hip extensors, hip abductors, hip adductors, knee extensors, knee flexors, and ankle dorsiflexors and plantarflexors.

Each muscle group will be tested in standardized positions against gravity and manual resistance applied by the physiotherapist. Muscle strength will be graded using the standard 0-5 MMT scale, where 0 indicates no visible or palpable muscle contraction and 5 indicates normal muscle strength against maximal resistance.

An overall lower extremity muscle strength score will be calculated as the mean of the tested muscle groups. Scores will range from 0 to 5, with higher scores indicating greater muscle strength and lower scores indicating reduced muscle strength.

Lower extremity muscular endurance will be assessed using the 30-Second Sit-to-Stand Test, a valid and reliable measure of functional lower limb endurance. Participants will be instructed to rise to a full standing position and return to a seated position as many times as possible within 30 seconds, with their arms crossed over the chest.

The total number of correctly completed repetitions within 30 seconds will be recorded. Performance will be expressed as the number of repetitions completed in 30 seconds, with higher values indicating greater lower extremity muscular endurance and lower values indicating reduced endurance.

Lower extremity functional status will be assessed using the Lower Extremity Functional Scale (LEFS), a validated patient-reported outcome measure. The LEFS is a self-administered questionnaire consisting of 20 items designed to evaluate an individual's ability to perform everyday functional activities.

Each item is scored on a 5-point Likert scale ranging from 0 (extreme difficulty or unable to perform the activity) to 4 (no difficulty). The total LEFS score will be calculated by summing all item scores, resulting in a total score ranging from 0 to 80.

Scores will be expressed as the total LEFS score (0-80), with higher scores indicating better lower extremity functional status and lower scores indicating greater functional limitation. Participants will complete the questionnaire under the supervision of a physiotherapist to ensure completeness.