LYMPHATIC RESEARCH AND BIOLOGY

Volume 00, Number 00, 2020

ª Mary Ann Liebert, Inc.
DOI: 10.1089/lrb.2020.0019

The Effects of Complete Decongestive Therapy

or Intermittent Pneumatic Compression Therapy
or Exercise Only in the Treatment of Severe Lipedema:
A Randomized Controlled Trial

Tuğba Atan, MD,1 and Yeliz Bahar-Özdemir, MD2

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Abstract

Background: Lack of diagnostic awareness of lipedema and frequent confusion with obesity or lymphedema
may be an obstacle for treatment. The clinical effects of conservative treatment methods are not clearly known.
This study investigated the effects of exercise-based rehabilitation combined with complete decongestive
therapy (CDT) or intermittent pneumatic compression therapy (IPCT) or alone in patients with severe lipedema.
Methods: Thirty-three women with severe (type 3, stage III or IV) lipedema diagnosed according to the revised-
Wold criteria were randomized into three groups: Group 1 (CDT plus exercises), Group 2 (IPCT plus exercises),
and Group 3 (control—exercises alone). All groups received 30 sessions of combined (aerobic, strengthening,
and stretching) exercise program. In addition, there were CDT in Group 1 and IPCT in Group 2 five times a
week for 6 weeks. The primary outcome measure was the limb volume measurements. The secondary outcome
measures were anthropometric measurements (body weight, body mass index, waist-to-height ratio, waist-to-
hip ratio), 6-minute walk test, visual analog scale for pain, fatigue severity scale, Beck Depression Inventory,
and Short Form Health Survey-36 (SF-36).
Results: Thirty-one participants completed the interventions. Limb volumes ( p = 0.017, gp2 = 0.562 for right;
p < 0.001, gp2 = 0.775 for left), pain ( p = 0.045, gp2 = 0.199), and physical functioning subscore of SF-36
( p = 0.040, gp2 = 0.465) differed significantly between treatments originating from Group 1.
Conclusions: All programs improved outcome measurements after the intervention. However, when the dif-
ference between treatments was investigated, CDT administered in addition to the exercises has been shown to
provide significant improvements in reducing limb volumes, pain, and physical function.
Clinical trial registration number: The study was registered at the US National Institutes of Health
(ClinicalTrials.gov) (NCT03924999) and available at https://clinicaltrials.gov/ct2/show/NCT03924999?term=
lipedema&draw=2&rank=6

Keywords: compression bandaging, lipedema, manual lymphatic drainage, physical activity

Introduction change in adolescence or after a few years. Bilateral sym-

metrical swelling, pain spontaneously or with palpation, and

L ipedema is a chronic, progressive, and hereditary

adipose tissue disorder characterized by an abnormal
increase of subcutaneous adipose tissue, especially in the
lower extremities. It is thought to affect *11% of women
in adulthood all over the world.1–3 Lipedema is often seen in
female sex, and usually begins in the period of hormonal
easy development of ecchymosis of the legs are the main
determinants of lipedema.4
Lipedema is often not diagnosed due to lack of awareness
of the physicians. Furthermore, it can be evaluated as obesity
and lymphedema. Patients with lipedema, who are said to be
obese, are directed to strict diet and exercise, but weight loss

1
Department of Physical Medicine and Rehabilitation, Gaziler Physical Therapy and Rehabilitation Education and Research Hospital,
Ankara, Turkey.
2
Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Hitit University, Corum, Turkey.

1
 2 ATAN AND BAHAR ÖZDEMIR
is from the upper extremity and trunk, which are nonlip-
edematous areas.3,5,6 Although lymphatic dysfunction is a
common finding in advanced stages, there are many distinc-
tive features between lymphedema and lipedema.2,4,6
There are accepted clinical diagnostic criteria for the di-
agnosis. It is divided into five types depending on the fat
distribution. In type 1, pelvis and hips; in type 2, from hip to
knee; in type 3, from hip to ankle; in type 4, arms; and in
type 5, lower limbs are affected.6 Pain is seen in 70%
of patients in the affected areas. Although the cause of the
pain is unknown, it has components seen in central sensiti-
zation and chronic pain syndrome.7 It is often accompanied
by fatigue and loss of physical condition.5,6
Four morphological stages have been defined. In stage I,
the skin surface is normal; the adipose tissue is increased
and may contain small nodules. In stage II, a larger fat mass
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and nodular changes are observed in the subcutaneous tis-
sue. In stage III, there are symmetrical large fat lobules and
skin folds around the medial knee, lateral hip, and ankle.
In stage IV, lipedema is accompanied by lymphedema (li-
polymphedema).6
Treatment for lipedema includes conservative and surgical
options. In conservative treatment, a holistic approach is re-
quired, involving patient education, diet, physical activity,
manual lymphatic drainage (MLD), compression therapy,
methods of coping with pain, and psychological support.5,8
Although there is no definite exercise prescription for
lipedema, physical activity with moderate intensity (60% to
70% of age adjusted predicted maximum heart rate) is re-
commended. It helps maintain weight control and increase
mobility as well as mental well-being.9 Also, staying active
in lipedema is important for the movement of lymph fluid.10
In patients with lipedema, volume reduction may not be
associated with exercise in lipedematous areas.11 In this
case, the main component of treatment is complete decon-
gestive therapy (CDT). Especially if lymphedema is accom-
panied and skin folds are present, MLD and bandaging with
multilayered short-stretch bandages before compression
clothes can be beneficial in reducing pain, tenderness, and
limb volumes. If CDT modalities cannot be applied or are
not sufficient, intermittent pneumatic compression therapy
(IPCT) can be used.12
The hypothesis of this study is that exercise-based rehabil-
itation combined with CDT will lead to greater improvements
in limb volumes, anthropometric measurements, functional
capacity, pain, fatigue, depression, and quality of life than
exercise-based rehabilitation combined with IPCT or alone in
patients with severe lipedema. Therefore, the aim of this study
was to compare the effects of exercises combined with CDT or
IPCT or alone in patients with severe lipedema.
Materials and Methods
Study design
The study was designed as a single-center, prospective,
single-blinded, randomized controlled trial. The study pro-
tocol was approved by the Institutional Human Research
Ethics Committee (approval number: 19-KAEK-062). All the
procedures were conducted according to the Declaration
of Helsinki. This study was also registered in the Clinical-
trials.gov database (NCT03924999). The reporting was
conducted in accordance with the Consolidated Standards of
Reporting Trials (CONSORT) and recommendations for
randomized trials. Participants were fully informed about the
experimental procedures and gave their informed consent.
Participants and assessments
Participants with diagnosis of lipedema were recruited
from the physical medicine and rehabilitation outpatient
clinic. Patients who were willing to participate in the study
were assessed to evaluate their eligibility for the study and to
provide detailed information about the study. The inclusion
criteria were as follows: (1) ‡18 years, (2) female sex, (3)
diagnosed with lipedema according to the criteria of revised
Wold.13 These criteria include disproportionate body fat dis-
tribution, no or limited influence of weight loss on fat distri-
bution, limb pain and bruising, increased sensitivity to touch or
limb fatigue, nonpitting edema, and no reduction of pain or
discomfort with limb lift. (4) Lipedema type 3 and stage III
or IV.6 (5) No participation in a designed sports or exercise
training programs within the last 3 months. (6) No pregnancy
or breastfeeding. Patients were excluded if they had comorbid
inflammatory/connective tissue diseases, cardiovascular or
musculoskeletal problems that could prevent them to partici-
pate in an exercise program. During the study, patients were
not allowed to change the drug doses they used for pain. The
study began on April 2019 and ended on November 2019.
The patients were randomized into three groups: Group 1
(CDT plus exercises), Group 2 (IPCT plus exercises), and
Group 3 (control—exercises only). Randomization was done
by using a computer program that included a randomized
table of numbers, which was created by an independent in-
dividual who was not involved in the recruitment and treat-
ment of patients. Numbered cards with a random assignment
and information about the group allocation in opaque, sealed
envelopes were prepared by the independent individual. The
certified therapist opened the envelope and applied the pro-
cedure according to randomization group.
Interventions
Complete decongestive therapy. Group 1 had 30 ses-
sions of CDT, which consisted of MLD, skin care, and com-
pression bandaging, five times a week for 6 weeks. The MLD
technique involved stationary circles, pumping, scooping,
and rotary movements with varying degrees of light pres-
sure. After MLD, compression bandaging with multilayered
short-stretch bandages was applied. The bandage was kept
23 hours and replaced the next day after exercise program.
CDT was provided by a certified lymphedema therapist.12
Intermittent pneumatic compression therapy. Group 2
had 30 sessions of IPCT, which consisted of applying
the device (I-tech lymphopress 4, Martellago (VE), Italy)
30 minutes with a setting of 50 mm Hg pressure, five times a
week, for 6 weeks.14,15
Exercise training
All participants followed the same standardized exercise
training and intensity protocols 5 days a week, for 6 weeks.
Each exercise session consisted of 5–10 minutes active
warmup, including flexibility exercises; 20–25 minutes sub-
maximal aerobic exercise with treadmill training; 10–15
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FIG. 1. Flow diagram of the study.

Table 1. Patient Characteristics of the Study Groups

Variables Group 1 (n = 11) Group 2 (n = 10) Group 3 (n = 10) p
Age, years, mean (SD) 58.36 (8.98) 58.90 (7.70) 60.10 (5.50) 0.868
Height, cm, mean (SD) 150.81 (6.33) 156.30 (7.14) 156.20 (5.67) 0.096
Weight, kg, mean (SD) 99.08 (11.52) 97.52 (9.00) 102.27 (13.00) 0.636
BMI, kg/m2, mean (SD) 43.49 (4.44) 40.66 (3.81) 42.06 (5.76) 0.402
Education level
Low, n (%) 0 (0%) 1 (10%) 0 (0%) 0.370
Intermediate, n (%) 11 (100%) 9 (90%) 9 (90%)
High, n (%) 0 (0%) 0 (0%) 1 (10%)
Duration of disease, years, mean (SD) 11.36 (2.83) 11.60 (3.13) 10.90 (2.76) 0.862
Lipedema
Stage 3, n (%) 3 (27.3%) 3 (30%) 3 (30%) 0.987
Stage 4, n (%) 8 (72.7%) 7 (70%) 7 (70%)
IPAQ, total score (MET/min), mean (SD) 381.63 (455.16) 233.85 (149.44) 425.70 (286.92) 0.401
Right limb volume, mL 11911.1 (2616.9) 10953.9 (1298.0) 12251.9 (2623.2) 0.428
Left limb volume, mL 12039.8 (2748.1) 10531.2 (1263.1) 11924.5 (2263.5) 0.245
Volume difference between both limbs, mL 853.2 (952.7) 553.5 (288.0) 486.7 (456.1) 0.392
Group 1: CDT plus exercises group, Group 2: IPCT plus exercises group, and Group 3: control, exercises-only group.
BMI, body mass index; CDT, complete decongestive therapy; IPAQ, International Physical Activity Questionnaire; IPCT, intermittent
pneumatic compression therapy; SD, standard deviation.

3
 Table 2. Within- and Between-Group Changes (Group, Time, and Interaction Effects)
for Primary and Secondary Outcome Measurements
Group ·
Group Time Time
Outcome p-Value p-Value p-Value
measurements Group 1 Group 2 Group 3 p-Valuea gp2 gp2 gp2
Body weight (kg)
Preintervention 99.08 (11.52) 97.52 (9.00) 102.27 (13.00) 0.636
Postintervention 97.40 (11.65) 96.03 (9.07) 100.28 (13.59) 0.671 <0.001 0.749
p-Valueb <0.001 0.020 0.005 0.028 0.597 0.020
BMI (kg/m2)
Preintervention 43.49 (4.44) 40.66 (3.81) 42.06 (5.76) 0.403
Postintervention 42.78 (4.66) 39.66 (3.12) 41.17 (5.88) 0.361 <0.001 0.789
b
p-Value <0.001 0.070 0.001 0.070 0.466 0.017
Waist-to-height ratio
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Preintervention 0.73 (0.05) 0.66 (0.05) 0.71 (0.07) 0.064 0.090 <0.001 <0.001
Postintervention 0.70 (0.05) 0.65 (0.05) 0.70 (0.06) 0.158 0.818 0.496
p-Valueb <0.001 0.004 0.012
Waist-to-hip ratio
Preintervention 0.86 (0.06) 0.82 (0.04) 0.84 (0.06) 0.418
Postintervention 0.85 (0.69) 0.82 (0.04) 0.85 (0.06) 0.462 0.980 0.062
p-Valueb 0.064 0.573 0.292 0.054 0.001 0.180
Right limb volume, mL
Preintervention 11911.1 (2616.9) 10953.9 (1298.0) 12251.9 (2623.2) 0.428
Postintervention 10758.1 (2477.5) 10283.1 (1158.7) 11709.9 (2633.3) 0.017 <0.001 0.001
p-Valueb <0.001 0.022 0.028 0.562 0.842 0.378
Left limb volume, mL
Preintervention 12039.8 (2748.1) 10531.2 (1263.1) 11924.5 (2263.5) 0.245
Postintervention 10841.9 (2588.9) 10001.7 (1312.5) 11316.8 (2376.7) <0.001 <0.001 <0.001
p-Valueb <0.001 0.031 0.023 0.775 0.878 0.522
6MWD, m
Preintervention 304.81 (105.39) 321.70 (92.85) 328.30 (59.80) 0.822
Postintervention 367.81 (123.47) 375.80 (77.35) 369.29 (93.08) 0.943 <0.001 0.554
p-Valueb 0.050 0.036 0.009 0.004 0.480 0.043
VAS for pain
Preintervention 7.73 (1.67) 8.30 (1.70) 7.90 (1.47) 0.677
Postintervention 3.09 (1.92) 4.90 (1.37) 5.70 (1.94) 0.045 <0.001 0.029
p-Valueb <0.001 0.001 0.002 0.199 0.768 0.223
Fatigue severity scale
Preintervention 5.67 (1.26) 5.77 (0.67) 4.80 (1.10) 0.092 0.118 <0.001 0.622
Postintervention 4.54 (1.19) 4.96 (1.02) 4.09 (1.27) 0.142 0.457 0.033
b
p-Value 0.016 0.015 0.020
Beck depression scale
Preintervention 24.18 (9.80) 25.20 (6.47) 23.60 (7.18) 0.903 0.341 <0.001 0.243
Postintervention 14.81 (3.48) 21.00 (5.18) 18.10 (5.52) 0.074 0.465 0.096
p-Valueb 0.004 0.094 0.014
SF-36 physical functioning
Preintervention 31.36 (12.26) 29.00 (15.23) 32.50 (27.30) 0.676
Postintervention 53.18 (14.19) 39.50 (16.06) 46.00 (17.13) 0.040 <0.001 0.739
p-Valueb 0.003 0.007 0.102 0.214 0.474 0.021
SF-36 Role limitations due to physical health
Preintervention 11.36 (25.89) 12.50 (17.67) 21.00 (34.05) 0.675
Postintervention 31.81 (27.59) 20.00 (19.72) 15.00 (17.48) 0.853 0.065 0.028
p-Valueb 0.005 0.279 0.452 0.011 0.116 0.226
SF-36 role limitations due to emotional problems
Preintervention 15.13 (17.39) 13.33 (23.30) 13.33 (32.20) 0.981
Postintervention 36.34 (34.81) 16.66 (23.57) 33.33 (35.14) 0.550 0.019 0.410
p-Valueb 0.067 0.591 0.168 0.042 0.281 0.062
(continued)

4
 CONSERVATIVE TREATMENT METHODS FOR LIPEDEMA 5

Table 2. (Continued)
Group ·
Group Time Time
Outcome p-Value p-Value p-Value
measurements Group 1 Group 2 Group 3 p-Valuea gp2 gp2 gp2
SF-36 Energy/fatigue
Preintervention 31.36 (16.13) 36.50 (24.04) 38.20 (13.54) 0.917
Postintervention 52.27 (18.75) 56.00 (18.52) 52.50 (16.87) 0.465 <0.001 0.438
b
p-Value 0.004 0.101 0.114 0.053 0.376 0.057
SF-36 Emotional well-being
Preintervention 44.00 (18.24) 43.60 (10.05) 42.90 (20.34) 0.989
Postintervention 64.36 (11.79) 51.20 (14.33) 53.20 (17.69) 0.425 0.001 0.247
p-Valueb 0.019 0.103 0.040 0.059 0.355 0.095
SF-36 social functioning
Preintervention 37.50 (24.36) 35.00 (17.48) 47.60 (18.61) 0.359
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Postintervention 56.81 (10.25) 56.25 (14.73) 63.75 (18.11) 0.270 <0.001 0.851
p-Valueb 0.011 0.016 0.014 0.089 0.492 0.011
SF-36 pain
Preintervention 27.25 (16.26) 25.25 (18.33) 30.25 (14.59) 0.801 0.260
Postintervention 51.50 (18.82) 57.50 (19.68) 47.75 (20.49) 0.082 <0.001 0.092
p-Valueb <0.001 0.002 0.016 0.216 0.629
SF-36 general health
Preintervention 21.81 (15.85) 30.00 (15.81) 32.50 (16.37) 0.290
Postintervention 41.36 (12.26) 35.50 (9.55) 38.50 (14.53) 0.744 0.001 0.090
p-Valueb 0.004 0.335 0.193 0.021 0.316 0.158
SF-36 Health change
Preintervention 35.00 (24.15) 36.36 (17.18) 38.50 (22.11) 0.933
Postintervention 67.50 (12.07) 59.09 (25.67) 55.00 (22.97) 0.830 <0.001 0.353
p-Valueb 0.002 0.024 0.031 0.013 0.512 0.072
Group 1: CDT plus exercises group, Group 2: IPCT plus exercises group, and Group 3: control, exercises-only group.
Data expressed as mean (standard deviation), gp2 = partial eta-squared, effect size.
a
p-Value for basal measurements among the three groups.
b
p-Value for pre- and postintervention measurements for each group.
Significant p-values ( p < 0.05) are indicated in bold and adjusted for Bonferroni correction.
6MWD, 6-minute walk distance; BMI, body mass index; SF-36, Short Form Health Survey-36; VAS, visual analog scale.

minutes of strengthening exercises where major muscle
groups were strengthened through shoulder press, dumbbell
press, shoulder elevation with resistance, biceps curl, squats,
hip flexion and extension, and standing hip exercises using
1–3 kg of weight loads and 1 set of 8–10 repetitions and a
5–10 minute cool-down involving stretching by holding the
main muscle-tendon groups for 20–30 seconds, with 4–5
repetitions for each muscle group. Aerobic exercise intensity
was adjusted according to 6-minute walk distance (6MWD).
Heart rate achieved at the end of the 6-minute walk test
(6MWT) was regarded as the target heart rate. This exercise
intensity was submaximal, and the heart rate and blood
pressure were measured during training sessions, and tread-
mill speed was tailored to reach the target heart rate. Main-
tenance of the heart rate during training sessions was important
both for providing the similar exercise intensity for each
patient.16,17 All exercise sessions were supervised by the
same physiotherapist.
The patients in Group 1 were wearing compression ban-
dages during exercise. The patients in the other group did not
have anything except the knee brace.
vention. Baseline demographic (age, height, weight, body mass
index, education level) and clinical characteristics (duration of
disease, stage of disease, level of physical activity according to
the International Physical Activity Questionnarie18) of the pa-
tients who met the initial screening criteria were recorded.
Outcome measurements were made at the same time of the day.
The evaluation included anthropometric measurements, limb
volume measurements, 6MWT, visual analog scale for pain,
fatigue severity scale (FSS), Beck Depression Inventory, and
Short Form Health Survey-36 (SF-36).
Number of sessions, total duration of aerobic exercise, and
duration of maximum aerobic exercise were also recorded
to determine compliance with the training program between
the groups.
Primary outcome
Limb volume measurements. Limb volume measurements
were chosen as the primary outcome measure. Circumference
measurements were taken at 4 cm intervals up the limb, from the
ankle to the thigh. Pythagorean theorem in the excel program
will automatically calculate limb volume measurements.19

Outcome measures Secondary outcomes

All participants evaluated pre- and postintervention by a Six-minute walk test. The 6MWT is a submaximal exercise
single investigator who was blinded to the allocated inter- test usually corresponding to 80% of a subject’s maximum
 6 ATAN AND BAHAR ÖZDEMIR
heart rate, and is used to assess functional capacity and
treatment response. Standard instructions were used, and
6MWD was recorded.20
Visual analog scale for pain. Pain intensity was measured
with visual analog scale for pain (0–10 mm; 0 means no pain,
10 means severe pain), which is used to measure musculo-
skeletal pain with very good reliability and validity.21
Fatigue Severity Scale. The FSS assesses the severity of
fatigue during the last week in a 9-item question-
naire (1 = strongly disagree, 7 = strongly agree). Total score
ranges from 9 to 63, with higher scores representing greater
fatigue.22
Beck Depression Inventory. The BDI is a 21-item self-
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report questionnaire evaluating the presence and severity of
depressive symptoms in the vegetative, emotional, cognitive,
and motivational domains. Scores for each item range from
0 to 3; higher scores mean higher risk of depression.23
Short Form Health Survey-36. SF-36 contains 36 items,
which are used to evaluate the quality of life of patients with
chronic pain. It measures eight different domains that address
physical functioning, physical role limitation, pain, general
health, vitality, social functioning, emotional role limitation,
and mental health. The score of each domain ranges from
0 (worse quality of life) to 100 (best quality of life).24
FIG. 2. The difference between treatments for the right limb volume.
Sample size. The sample size estimation was per-
formed using the G Power software (v 3.1). It was deter-
mined that 10 individuals for each group must be recruited
to detect a difference at 5% type 1 error level with 80%
power for an effect size of 0.467 based on the lower ex-
tremity limb volume reported in the previous research
conducted by Szolnoky et al., evaluating the CDT alone or
combined with IPCT in women with lipedema.8 However,
including *10% for possible future losses, 11 individuals
were allocated in three groups.
Statistical analysis
Demographic data and clinical features were presented as
mean and standard deviation (SD). Categorical variable was
presented as number (n) and percentage (%). Visual assess-
ment and Shapiro–Wilk test were used for normality evalu-
ation. All continuous variables were normally distributed.
A 3 (group) · 2 (time) mixed factorial analysis of variance
with repeated measures was used to assess the study out-
comes. Post hoc comparisons were done with the Bonferroni
test. The effect size was calculated by the partial eta squared
(gp2) value. Effect size values were interpreted as follows:
>0.2, large effect size; >0.1, medium effect size; and >0.05,
small effect size. Data analyses were performed using IBM
SPSS (Statistical Package for Social Sciences) Statistics
for Windows, Version 21.0, and p £ 0.05 was considered a
statistically significant difference.
 CONSERVATIVE TREATMENT METHODS FOR LIPEDEMA
Results
The CONSORT diagram for participants is shown in
Figure 1. Ninety-two individuals were assessed for eligibil-
ity, and 33 met the inclusion criteria and enrolled in the
study. Two of them lost to follow-up, and 31 participants
completed the program. Demographic and clinical vari-
ables did not show any significant difference between the
three study groups such as age, height, weight, BMI, and
education level (all p > 0.05). No significant differences
were found in the mean duration of disease, lipedema stage,
International Physical Activity Questionnaire total score,
right/left limb volume, and volume difference between
both limbs between the three groups of patients (all
p > 0.05) (Table 1).
The anthropometric measurements of body weight,
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body mass index, waist-to-height ratio, and waist-to-hip
ratio did not differ between treatments (all p > 0.05) but
changed over time (all p < 0.001), except for waist-to-hip
ratio ( p = 0.980) (Table 2).
A significant group effect, time effect, and interaction ef-
fect were found for the right and left limb volumes as our
primary outcome measurement (group effect: p = 0.017,
p < 0.001, respectively; time effect: p < 0.001 for both; inter-
action effect: p = 0.001, p < 0.001, respectively). Effect sizes
were large regarding treatments, time, and interaction. The
difference between treatments was originating from Group 1
( p < 0.001 for both) (Figs. 2 and 3).
FIG. 3. The difference between treatments for the left limb volume.
7
The 6MWD did not differ between treatments ( p = 0.943)
but changed over time ( p < 0.001). There were no significant
changes regarding the interactions between groups ( p = 0.554).
Effect sizes were small regarding treatments and interaction,
but large for time.
A significant group effect ( p = 0.045), time effect
( p < 0.001), and interaction effect ( p = 0.029) were found for
the pain. Effect sizes were large regarding time and interac-
tion, but medium for treatments. The difference between
treatments was originating from Group 1 ( p = 0.05, Fig. 4).
The FSS and beck depression inventory (BDI) did not
differ between treatments ( p = 0.118, p = 0.341, respectively)
but changed over time ( p < 0.001 for both). There were
no significant changes regarding the interactions between
groups ( p = 0.622, p = 0.243, respectively). Effect size was
small regarding interaction, but large for time.
The SF-36 subgroups did not differ between treatments
except for physical functioning ( p = 0.040) but changed over
time usually. Effect sizes were large regarding treatments and
time for physical functioning and pain subscores. A signifi-
cant interaction effect was found for only role limitations due
to physical health ( p = 0.028).
Training sessions were well tolerated, and no adverse
events were observed except mild pain in the lower extrem-
ities. The compliance with the training program determined
by mean number of sessions, mean duration of aerobic ex-
ercise, and mean duration of maximal aerobic exercise was
similar among the groups (all p > 0.05) (Table 3).
 8 ATAN AND BAHAR ÖZDEMIR
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FIG. 4. The difference between treatments for the pain measured by VAS. VAS, visual analog scale.

Discussion verity of the disease, the patient’s complaints and expecta-

The main findings from this study reinforce the recom-
mendations that lipedema patients should perform structured
exercises, particularly performed at a moderate intensity, to
improve anthropometric measurements including limb vol-
umes, functional capacity, pain, fatigue, depression, and qual-
ity of life. All of the groups showed improvements over time
in most outcome measures. One of the findings supported the
hypothesis that the limb volume measurements showed more
significant decrease for CDT group compared with other two
groups. Similar findings were observed for pain and SF-36
subgroup of physical functioning.
There is no targeted therapeutic treatment for patients with
lipedema, since etiological factors have not been fully es-
tablished.25 The goal of the treatment is to improve psycho-
social status, quality of life with regression of symptoms, and
prevent secondary complications such as lymphedema.2,3
Treatment options should be arranged according to the se-
tions in the light of current guidelines.26
The main treatment methods are CDT and surgical inter-
ventions. CDT is necessary and useful, especially in cases of
lipolymphedema. It is not surprising to use CDT and IPCT
treatments based on the link between lymphatic dysfunction
and adipose hypertrophy.8,27 CDT in lipedema consists of
MLD and compression treatments. MLD has been reported
to reduce pain and discomfort in pure lipedema patients.8 In an
uncontrolled study, a 10% reduction in leg circumference was
achieved with compressive therapy in lipedema women.8,12
In this study, when the limb volumes were compared be-
tween three groups after treatment, CDT plus exercises were
found superior. However, when the pre- and postintervention
measurements were compared, a significant improvement was
found also in IPCT plus exercises and exercises-only groups.
Pneumatic compression devices do not reduce adipose
tissue alone, but they can increase mobility by reducing
edema and pressure in lipedema. Nevertheless, they can also

Table 3. Features of Completed Training Sessions

Group 1 (n = 11) Group 2 (n = 10) Group 3 (n = 10)
Variables Mean (SD) Mean (SD) Mean (SD) p
No. of sessions 30.00 (0.00) 30.00 (0.00) 27.30 (5.69) 0.112
Total duration of aerobic exercise, min 20.45 (1.50) 20.80 (1.68) 21.30 (2.11) 0.558
Duration of maximal aerobic exercise, min 15.00 (1.67) 15.70 (1.49) 15.40 (0.84) 0.521
Group 1: CDT plus exercises group, Group 2: IPCT plus exercises group and Group 3: control, exercises-only group.
 CONSERVATIVE TREATMENT METHODS FOR LIPEDEMA
increase pain due to the sensitivity of patients with lipedema.
However, in this study, not an increase in pain, but rather a
significant reduction was achieved in the IPTC plus exercises
group. In addition, when the treatments for pain relief were
compared, the CDT plus exercises group was superior.
In a study by Szolnoky et al., no additional benefit of IPCT
added to CDT was found in women with lipedema. IPCT has
not been shown to be superior to MLD, but it may benefit in
cases where MLD is not applicable.8 According to the results
of this study, IPCT applied in addition to exercises was not
superior to the exercises-only group in patients with severe
lipedema.
Lipedema is a chronic condition, and decreased activity in
patients results in loss of muscle strength. Daily activities can
be highly affected in advanced stages.28 Decreased physical
activity leads to an increase in body mass index and lipede-
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ma. In this study, when the characteristics of the patients were
examined, the body mass index of the patients in all groups
was similarly high, and their physical activity levels were
low. In a study, quadriceps muscle strength was found to
be less in individuals with lipedema than in obese.29,30
Moderate-intensity physical activity is aimed at preventing or
reducing these conditions.31–34 In addition, exercise pro-
grams that increase muscle strength should be designed.
Flexibility exercises are also designed to increase the reduced
range of motion.29
To the best of our knowledge, this is the first single-blinded
randomized controlled trial that analyzes the effects of su-
pervised exercise sessions combined with CDT or IPCT in
patients with severe lipedema. When the outcome measures
determined for this study were examined, improvements
were achieved in all three groups in terms of weight control,
limb volumes, functional capacity, pain, fatigue, depression,
and quality of life. Importantly, interventions were well tol-
erated, and participants reported few adverse events such as
muscle or joint pain. Although participants had severe lipe-
dema, adherence to the treatments was high in all groups.
Study limitations
As a limitation of this study, the follow-up period was short
for understanding the maintenance of the long-term effects
of interventions. Further studies are necessary to determine
the long-term effects of interventions in subjects with lipe-
dema. Another limitation of the study is that the target group
only included stages III and IV. In future studies, it can be
investigated whether the treatments will have an effect on
early stage (stages I and II) patients. In addition, only clinical
diagnostic criteria for lipedema were used in this study. Stage
4 lipedema was detected with a positive ‘‘stemmer sign.’’ In
future studies, some delayed lymphatic flow and increase in
lymphatic pooling can be detected with lymphoscintigraphy
due to the mass effect of adipose tissue.
Conclusions
As a result, 30 sessions of CDT plus exercises, IPCT plus
exercises, and exercises only were found beneficial in severe
lipedema treatment; among them CDT was found to be su-
perior to others. CDT improved limb volumes, pain, and
physical functioning more than other treatment methods.
Planning the appropriate treatment by predicting the needs of
the patient should be the main target in this patient group.
9
Acknowledgments
The authors thank all participants of this study and lym-
phedema therapist Esin Cxatakkaya for providing treatments
for the participants.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-profit
sectors.
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Address correspondence to:
Tuğba Atan, MD
Department of Physical Medicine and Rehabilitation
Gaziler Physical Therapy and Rehabilitation
Education and Research Hospital
Ankara 06800
Turkey
E-mail: tubaatan@gmail.com