This randomized controlled study aims to investigate the effects of virtual reality (VR)-assisted gait training, in addition to Complex Decongestive Therapy (CDT), on gait parameters, physical function, quality of life, and edema levels in patients with lower extremity lymphedema. Lymphedema is a progressive condition characterized by the accumulation of protein-rich fluid due to lymphatic drainage insufficiency, leading to chronic inflammation and fibrosis. It impairs gait patterns and reduces functional mobility. VR technologies, such as the RehaWalk system, provide interactive, personalized rehabilitation environments that enhance motor learning, motivation, and adherence to treatment. The study evaluates spatiotemporal gait parameters, three-zone foot analysis (heel, midfoot, forefoot), limb circumferences, ultrasound measurements (dermis, epidermis, subcutaneous fat thickness), and patient-reported outcomes. VR-based training offers a novel, engaging approach to improve physical rehabilitation outcomes in patients with lower limb lymphedema. No significant risks are expected in this study.
Age between 18 and 65 years
Diagnosis of unilateral lower extremity lymphedema following gynecological and/or oncological surgery
Stage 2 or 3 lymphedema
Decompensated heart, lung, or kidney failure
Uncontrolled hypertension
Presence of systemic infection
Local infections in the lower extremity such as erysipelas or cellulitis
Parallel
Complex Decongestive Therapy (CDT) plus virtual reality (VR)-assisted gait training group
Procedure/SurgeryThe intervention group will receive standard Complex Decongestive Therapy (CDT) combined with virtual reality (VR)-supported walking exercises using the Rehawalk device. The Rehawalk system, which provides visual and auditory step guidance within a virtual environment, will be used to conduct the walking exercises at Gaziler Physical Therapy and Rehabilitation Training and Research Hospital. Participants will perform the VR-supported walking exercises for 20 minutes, five days a week, under the supervision of a physiotherapist. During these exercises, the affected lower limb will be multi-layer bandaged according to the standard CDT protocol. This combined treatment approach aims to improve gait parameters, functional capacity, edema control, and overall quality of life. Assessments will be carried out before and after the 4-week treatment period to evaluate the added benefits of VR-supported walking exercises alongside standard CDT.
Complex Decongestive Therapy alone group
Other interventionThe control group will receive only the standard Complex Decongestive Therapy (CDT). This treatment will be administered daily and consists of manual lymphatic drainage for 20 minutes, multi-layer compression bandaging for 10 minutes, skin and nail care for 5 minutes, patient education for 5 minutes, and therapeutic exercises including joint range of motion, stretching, and breathing exercises for 20 minutes. No virtual reality or additional gait training interventions will be applied to this group. Assessments will be conducted before and after the 4-week treatment period to evaluate the effects of CDT alone on functional capacity, quality of life, edema levels, and walking parameters.
Gait parameters
Spatiotemporal gait parameters (walking speed, cadence, step length, stride length, stance time, swing time) and plantar pressure distribution (peak pressure and contact time in heel, midfoot, and forefoot regions) will be assessed using the Rehawalk® instrumented treadmill system (zebris Medical GmbH, Germany). All parameters will be reported as individual continuous variables. Participants will walk barefoot at self-selected comfortable speed; data will be recorded for 30-60 seconds during steady-state walking after 1-2 minutes adaptation.
Lower extremity circumferential volume measurements
Circumferential measurements will be performed on the affected extremity with the patient in a semi-seated position, the ankle in neutral and the knee in extension. Measurements will begin at the ankle (medial malleolus) and continue at 4 cm intervals up to the inguinal region. After treatment, all patients' lymphedematous extremities (unilateral) will be measured a second time by the same evaluator using the same method, and the measurements will be recorded. The measurement data will be used to calculate the volume of the limb segments using the frustum formula for truncated cones, processed via Microsoft Excel. Pre- and post-treatment circumferential measurement data will be entered into the program to calculate extremity volumes and volume differences between extremities (in milliliters and percentage).
Dermal-epidermal thickness and subcutaneous tissue thickness measured by ultrasonography (USG)
Ultrasonographic evaluation will include measurement of the dermo-epidermal complex thickness, subcutaneous tissue thickness, and subcutaneous fluid accumulation. Additionally, sonographic pattern analysis will be performed to assess homogeneity, differences in echogenicity, fibrotic bands, and irregularities. Other findings such as lymphatic lakes and fascial delamination will also be evaluated.
Quality of life assessment -Lymphedema Quality of Life Questionnaire-Leg (LYMQOL-Leg)
Lymphedema Quality of Life Questionnaire-Leg (LYMQOL-Leg): This is a disease-specific quality of life scale for patients with lymphedema, consisting of 22 questions organized into 4 sections.Each item is scored on a 4-point Likert scale. Domain scores range from 0 to 7, with higher scores indicating worse quality of life. An overall quality of life item is scored from 0 to 10, with higher scores indicating better overall quality of life.
Functional capacity - Timed Up and Go Test (TUG)
Functional capacity assessment using the Timed Up and Go Test (TUG). Timed Up and Go Test (TUG): This test measures the speed at which patients perform several functional maneuvers including standing up from a chair, walking, turning, and sitting down.
Functional status - Lower Extremity Functional Scale (LEFS)
Functional status will be evaluated using the Lower Extremity Functional Scale (LEFS). This questionnaire consists of 20 items assessing the patient's ability to perform daily activities involving the lower extremities. Each item is scored from 0 to 4, resulting in a total score ranging from 0 to 80, with higher scores indicating better functional condition.
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