Management of physical activity using a wearable device during intensive decongestive therapy in patient with lower limb lymphedema: a case report

Abstract

[Purpose] Lymphedema is a chronic, progressive disorder impairing function and quality of life. Although complete decongestive therapy (CDT) is standard, optimal regulation of physical activity during CDT is unclear. This case report evaluated the feasibility of wearable device use during intensive CDT. [Participant and Methods] A 78-year-old woman with bilateral lower limb lymphedema after cervical cancer surgery and radiotherapy underwent a 2-week inpatient CDT program. Assessments included limb circumference, Timed Up and Go test (TUG), skin mechanical properties (Cutometer^®), body water distribution (ECW/TBW ratio), and quality of life (LYMQOL-Leg). A Fitbit^® device continuously monitored steps, distance, energy expenditure, and sleep. A 7,000-step daily goal was collaboratively set. [Results] After CDT, limb circumference and ECW/TBW ratio decreased, with improvements in skin parameters and mobility (shorter TUG times). LYMQOL-Leg scores improved across function, symptoms, and emotions. Fitbit^® data confirmed adherence to the step goal, facilitating shared use of activity information. [Conclusion] Wearable devices can be integrated into CDT, providing objective, continuous activity data to support adherence and collaborative goal setting. Such monitoring may enhance engagement, optimize exercise under compression, and guide individualized rehabilitation for lymphedema.

INTRODUCTION

Lymphedema is a chronic and progressive condition characterized by the accumulation of protein-rich fluid in interstitial tissues due to impaired lymphatic drainage¹⁾. Lower limb lymphedema can lead to significant functional limitations, recurrent infections, and a decline in quality of life²⁾. The causes include cancer treatment, venous disorders, and congenital lymphatic abnormalities; however, in Japan, lymphedema associated with cancer treatment is the most common. Because lymphedema is a chronic condition, long-term management strategies tailored for each patient are required.

The gold standard for managing lymphedema is complete decongestive therapy (CDT), which combines manual lymphatic drainage, compression therapy, exercise, and skincare. Intensive inpatient CDT effectively reduces limb volume^{3, 4)}. Despite its clinical benefits, management of physical activity during therapy remains challenging. In particular, no optimal solution has been established for regulating activity levels during exercise therapy under compression⁵⁾, which is considered one of the most effective components of CDT. Therefore, monitoring and optimizing daily activity levels during CDT are crucial for maximizing the therapeutic outcomes.

In recent years, wearable devices such as Fitbit^® (Fitbit Inc., San Francisco, CA, USA) have been increasingly adopted in rehabilitation and chronic disease management. These devices provide continuous and objective data on physical activity, including step count, activity intensity, and energy expenditure. Unlike traditional self-report measures, wearable devices allow real-time monitoring and personalized feedback, which may enhance patient engagement and adherence. In the context of lymphedema management, however, evidence on the feasibility and utility of such devices remains limited⁶⁾. In chronic disease populations, wearable activity monitors have been shown to facilitate objective assessment of daily activity, enhance adherence to rehabilitation programs, and promote patient engagement through feedback and goal setting⁷⁾. Although evidence specific to lymphedema remains limited, these findings suggest that wearable technology may serve as a supportive tool in the management of long-term rehabilitation conditions.

This case report describes the use of a Fitbit^® to monitor and manage physical activity during an intensive decongestive therapy program for a patient with lower limb lymphedema. By presenting objective activity data alongside clinical outcomes, this report aimed to highlight the potential role of wearable technology in supporting individualized rehabilitation strategies for patients with lymphedema.

CASE

The case was fully explained both orally and in writing, and informed consent was obtained for this report.

A 78-year-old woman (height: 154.6 cm; body weight: 58.4 kg; BMI: 24.4 kg/m²) with a history of cervical cancer underwent radical hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy (RH + BSO + PLN) approximately 23 years ago, followed by adjuvant radiotherapy. Approximately 10 years after surgery, she developed bilateral lower limb lymphedema. The condition was managed with CDT and compression stockings. However, she experienced recurrent episodes of cellulitis and developed septic arthritis of the hip during the course of the disease. In recent years, her lymphedema has gradually worsened, predominantly affecting the right lower limb, although the left lower limb also showed progressive swelling. Due to the increasing severity of her condition, she was admitted specifically for a planned 2-week intensive inpatient complete decongestive therapy (CDT) program for lymphedema management. At our institution, short-term hospitalization is routinely implemented for patients with advanced lymphedema who require intensive CDT under structured supervision. At the time of admission, both cellulitis and septic arthritis had completely resolved. Furthermore, other conditions presenting with edema were excluded from the diagnosis. During the intervention period, the patient was not receiving diuretics, analgesics, or any medications known to significantly affect fluid balance or physical activity. No medication changes occurred during hospitalization. Although she had a history of septic arthritis of the hip, the condition had completely resolved prior to admission, and no acute mobility-limiting disorders were present during the intervention period.

The intensive inpatient CDT program at our institution typically lasts for two weeks. During this period, daily assessments of edema morphology are conducted, and comprehensive evaluations of edema morphology, motor function, and quality of life are performed upon admission and discharge. Edema assessment and treatment during the hospitalization were primarily conducted by the same occupational therapist with 14 years of clinical experience in oncology rehabilitation. In addition, a certified lymphedema nursing therapist with more than 40 years of clinical experience was involved in patient care. The lymphedema certification was obtained through a nationally recognized training program that fulfills institutional requirements for reimbursement of lymphedema management under the Japanese healthcare system.

Upon admission, the right lower extremity was classified as having ISL stage 3 disease, whereas the left lower extremity was classified as having late stage 2 disease. Circumference, skin mechanical properties, body composition, and quality of life were assessed, and the results are summarized in Table 1 and Fig. 1.

Table 1. Changes in body composition, physical function, skin mechanical properties, and quality of life.

		Pre-intervention	After one week	After two weeks
Body weight (kg)		58.4	55.1	54.6
BMI (kg/m2)		24.4	23.1	22.8
Girth (cm) right / left
	Groin	55.0 / 52.0	54.4 / 52.4	54.0 / 52.6
	Thigh (12 cm above the knee)	51.0 / 48.0	48.0 / 43.2	44.2 / 44.0
	Knee	45.0 / 38.4	39.8 / 35.0	38.2 / 34.4
	Lower leg	43.8 / 40.0	47.0 / 33.0	37.0 / 33.8
	Ankle joint	25.6 / 23.0	21.0 / 19.6	21.0 / 18.0
	Dorsum of the foot	22.0 / 20.4	20.4 / 18.4	20.0 / 18.0
Skin mechanical properties Thigh (right / left)
	R0 + offset (mm)	1.684 / 1.699	1.702 / 1.707	1.736 / 1.737
	R2 (%)	45.4 / 51.8	54.2 / 54.8	55.2 / 62.1
	R5 (%)	30.4 / 44.0	40.4 / 47.8	41.5 / 50.1
	R7 (%)	29.8 / 42.0	37.8 / 42.7	39.0 / 46.6
Lower limb (right / left)
	R0 + offset (mm)	1.678 / 1.657	1.692 / 1.662	1.721 / 1.690
	R2 (%)	37.5 / 41.0	41.0 / 41.5	45.5 / 44.0
	R5 (%)	28.6 / 31.3	33.3 / 36.7	33.8 / 38.7
	R7 (%)	25.2 / 27.9	29.6 / 30.7	30.7 / 33.2
TUG (sec)		10.39	8.11	7.53
ECW/TBW		0.426	0.407	0.405
LYMQOL
	Function	1.63	1.7	1
	Appearance	1.43	1.3	1.3
	Symptoms	1.8	2	1
	Emotions	1	1.2	1
	Over all	8	8	8

BMI: body mass index; TUG: timed up and go test; ECW/TBW: extracellular water to total body water ratio; LYMQOL: quality of life measurement for limb lymphedema.

Fig. 1.

Morphological changes in both lower limbs before and after treatment, such as reduction in circumference.

Functional mobility was assessed using the Timed Up and Go (TUG) test, which measures the time required to stand up from a chair, walk 3 meters, turn, return, and sit down. Longer times indicated impaired mobility and functional decline.

The mechanical properties of the skin were assessed using a skin elasticity meter (Cutometer^®, Courage + Khazaka Electronic GmbH, Cologne, Germany). The device applied a negative pressure of 450 mbar for 3 s, followed by 3 s at atmospheric pressure (mode 1 setting) using a 2-mm probe. The measurement parameters included R0+offset (distensibility), R2 (gross elasticity), and R7 (biological elasticity), with higher values indicating improved skin performance. In accordance with previous studies⁸⁾, Cutometer^® measurements were performed at two standardized sites: 12 cm above the upper pole of the patella for the thigh, and at the point of maximum calf circumference for the lower leg.

Body water distribution was assessed using a bioelectrical impedance analyzer (InBody 770, InBody Co., Seoul, South Korea). Measurements were performed in the standing position in the morning, at least 2 hours after breakfast, under standardized resting conditions. The extracellular water to total body water ratio (ECW/TBW) was used as an indicator of fluid imbalance and edema, with higher ratios reflecting increased extracellular fluid retention.

Quality of life was assessed using the Lymphedema Quality of Life Questionnaire for the Leg (LYMQOL-Leg), which is a disease-specific scale for lower limb lymphedema. The questionnaire consists of four domains (function, appearance, symptoms, and emotions), where lower scores (range: 1–4) indicate better outcomes, and one overall score (range: 0–10) indicates better quality of life⁹⁾.

Lymphedema treatment consisted of complete decongestive therapy (CDT), including skin care, manual lymphatic drainage, compression therapy, and rehabilitation exercises performed under compression, together with structured patient education on edema self-management and nutritional counseling. Manual lymphatic drainage was performed twice daily for approximately 20–30 minutes per session.

Exercise therapy under compression was conducted twice daily and included low- to moderate-intensity aerobic walking, functional lower limb training, and active range-of-motion exercises. Each CDT and physical function training session lasted approximately 60 minutes in the morning and afternoon.

Compression therapy was performed using multilayer bandaging with MOBIDERM materials and was adjusted daily according to limb volume changes and skin condition. Bandaging was maintained throughout the day except during bathing.

Structured education and self-management guidance were provided several times during hospitalization, focusing on compression use, skin care, infection prevention, and long-term activity management. Nutritional counseling was delivered by a certified nutritionist and primarily focused on weight management and salt intake, with two formal sessions conducted during the inpatient period.

Prior to hospital discharge, the patient was fitted with elastic compression garments for both daytime and nighttime use. In addition, physical activity and lifestyle factors were continuously monitored using a wearable device (Fitbit^®). The activity data were reviewed daily by the treating therapist via the device application, allowing direct access to step counts and activity trends. Feedback was provided to the patient during routine rehabilitation sessions, and activity goals were adjusted collaboratively when necessary. This process enabled structured encouragement and individualized modification of the exercise program based on objective data.

A distinctive feature of this case intervention was the continuous, 24-hour monitoring of exercise therapy under compression using a Fitbit^® device. The wearable device provided a round-the-clock assessment of daily activity parameters, including step count, walking distance, energy expenditure, and sleep duration, except during bathing when the device was removed. This monitoring system was designed not only to promote patient self-management, but also to supply healthcare professionals with objective data, thereby enabling the shared use of activity information between patients and clinicians. This bidirectional, collaborative approach may represent a novel contribution to individualized lymphedema care. To the best of our knowledge, this is the first report describing the use of a continuously shared monitoring system for lymphedema management. In addition, as a shared goal with the patient, we set a target of 7,000 steps per day^{10, 11)}, which is generally considered effective in promoting health (Fig. 2).

Fig. 2.

Exercise therapy under compression therapy (one section).

The results of the interim assessment after one week of intervention and the final assessment after two weeks are summarized in Table 1. Overall, the patient showed favorable improvements across all assessment parameters. Limb circumference was reduced, skin mechanical properties improved, as indicated based on enhanced Cutometer^® values, and the ECW/TBW ratio decreased, suggesting better fluid balance. Functional mobility also improved with a shorter TUG time and quality of life as measured using the LYMQOL-Leg, demonstrating notable gains in function, symptoms, and emotional well-being. (Table 1, Fig. 1).

In addition, daily monitoring with the Fitbit^® device demonstrated that physical activity parameters such as step count, walking distance, and energy expenditure were effectively tracked and managed throughout the intervention period (Table 2). Importantly, the patient was able to consistently meet the shared target of more than 7,000 steps per day, highlighting the feasibility of wearable-based monitoring to support adherence and reinforce collaborative goal setting between patients and healthcare professionals. These results indicate that the intensive 2-week CDT program, supported by continuous wearable monitoring, was effective in alleviating lymphedema-related impairments and enhancing the patient’s overall physical function and quality of life.

Table 2. Wearable device monitoring results.

Day	Daily steps	Walking distance (km)	Calories consumed (kcal)	Sleep time (min)
Day 1	-	-	-	-
Day 2	3,200	-	-	-
Day 3	2,220	1.46	1,176	477
Day 4	6,868	4.25	1,420	502
Day 5	8,652	5.65	1,481	551
Day 6	10,167	6.45	1,535	524
Day 7	10,030	6.50	1,479	604
Day 8	10,414	6.64	1,515	508
Day 9	9,871	6.24	1,506	517
Day 10	10,609	6.71	1,520	492
Day 11	11,111	7.03	1,539	489
Day 12	10,191	6.46	1,504	-

-: No measurements were performed during hospital days 1–2 to allow case to acclimate to ward life under complex decongestive therapy.

DISCUSSION

We identified two important clinical insights. The first important insight was that intensive complete decongestive therapy (CDT) demonstrated clear clinical benefits even in a patient with lower limb lymphedema for more than 20 years. After two weeks of intensive inpatient CDT, the patient showed measurable improvements in limb circumference, skin mechanical properties, and extracellular water distribution, as indicated by a decrease in the ECW/TBW ratio. In addition, functional mobility, assessed using the Timed Up and Go (TUG) test, improved, and patient-reported outcomes measured using the LYMQOL-Leg demonstrated better scores across several domains. These findings emphasize that CDT contributes not only to morphological improvement but also to functional and psychosocial recovery. These improvements are considered to be primarily attributable to the established physiological effects of intensive CDT.

Long-standing lymphedema is generally accompanied by progressive tissue fibrosis and adipose deposition, leading to reduced treatment responsiveness¹²⁾. Nevertheless, the improvements observed in this case suggest that structured, intensive CDT may be effective in the chronic stages of the disease. Previous clinical studies have also reported that intensive inpatient CDT produces significant reductions in limb volume within a short time frame^{3, 4)}, and the present case reinforces these findings.

Improvements in the mechanical properties of the skin are particularly noteworthy. The increase in R2 (gross elasticity) measured using the Cutometer^® suggests that reversible tissue characteristics remained despite the chronicity of the condition¹³⁾. Furthermore, the decrease in the ECW/TBW ratio implies not only localized volume reduction, but also systemic fluid balance improvement, highlighting the physiological impact of CDT. Functionally, a shortened TUG time reflects enhanced mobility, which is clinically important given that patients with lymphedema often experience reduced ambulation and increased risk of falls¹⁴⁾. In addition, the improvement in LYMQOL-Leg scores indicated that physical benefits extended to psychological and social well-being, supporting the concept that lymphedema management should be approached as holistic rehabilitation. The observed reduction in TUG time exceeded 1 second, which has been suggested as a clinically meaningful change in older adults¹⁵⁾ and is relevant given the established fall-risk threshold of approximately 13.5 seconds¹⁶⁾. In addition, the decrease in the ECW/TBW ratio approached values reported in non-edematous populations, suggesting physiologically meaningful fluid redistribution. Although minimal clinically important differences for the LYMQOL-Leg have not been firmly established, the magnitude of score improvement was comparable to or greater than changes reported in previous interventional studies of lymphedema management.

The second important insight was the feasibility and utility of using a wearable device to monitor and manage daily physical activity during the CDT. The wearable device functioned as an adjunctive monitoring tool rather than as the primary driver of clinical improvement. Traditionally, activity levels in patients with lymphedema have been assessed using patient self-reports or therapist observations, both of which are limited by recall bias and subjectivity. Such methods make it difficult to optimize the balance between beneficial exercises under compression and the risk of excessive activity, which may exacerbate symptoms. In this case, continuous monitoring with a Fitbit^® provided objective and real-time data on step count, walking distance, and energy expenditure. This allowed clinicians to accurately evaluate the patient’s activity patterns and enabled shared goal setting, consistent with previously described models of shared decision-making and collaborative patient engagement in clinical practice^{7, 17)}.

A key feature was the establishment of a collaborative daily step target of 7,000 steps. The fact that the patient consistently met this target indicates not only the feasibility of wearable-based monitoring, but also its role in enhancing adherence to prescribed activity levels. Importantly, this approach promotes patient engagement by providing tangible feedback and fostering self-management. Previous studies on other chronic conditions such as heart failure and diabetes have reported that wearable devices can increase physical activity, improve adherence to rehabilitation programs, and enhance clinical outcomes⁷⁾. The present case suggests that similar benefits may be achieved with lymphedema care.

In the context of lymphedema management, the evidence for the use of wearable devices remains scarce⁶⁾. Most previous research has focused on volume reduction or compression therapy, with little attention paid to the objective quantification of activity levels. Therefore, this case provides preliminary evidence that wearables can be integrated into the CDT to optimize exercise intensity and monitor adherence in real-world settings. Moreover, the ability to continuously track activities offers an opportunity to refine individualized rehabilitation strategies, ensuring that patients remain active at levels that are both safe and therapeutically effective.

In addition to inpatient settings, the use of wearable technology may be highly relevant for long-term management. Lymphedema is a chronic progressive condition that requires sustained self-care after discharge. Adherence to compression, exercise, and weight management is often suboptimal in the long term, leading to the recurrence of swelling or complications such as cellulitis. Remote monitoring with wearable devices has the potential to support the continuity of care by providing clinicians with ongoing feedback and enabling early intervention if activity patterns suggest a risk of deterioration. Such systems could be further enhanced by integration with telemedicine platforms, allowing two-way communication and the reinforcement of behavioral strategies.

Nevertheless, several challenges remain to be addressed. The accuracy of consumer-grade wearable devices in patients with lymphedema, particularly those wearing multilayer compression bandages, remains unvalidated. Motion artifacts, device displacement, or skin changes may introduce measurement errors. In addition, while step counts provide a useful measure of ambulatory activity, they do not capture other forms of exercise such as resistance training or flexibility exercises, which may also be important components of CDT. Privacy and data security also require careful consideration, particularly if activity data are to be continuously shared with healthcare providers.

Taken together, this case demonstrates that wearable devices can play a valuable role as adjuncts to standard CDT by providing objective and continuous data on activity levels, enabling collaborative goal setting, and supporting patient adherence. Although further studies are needed to confirm its validity and clinical impact, the integration of wearable technology into lymphedema care may represent a promising step toward individualized, data-driven rehabilitation strategies, both during intensive inpatient programs and in long-term outpatient settings.

In conclusion, this case demonstrates that intensive CDT remains clinically effective in advanced lower limb lymphedema, while the adjunctive use of wearable activity monitoring provided objective and continuous data that facilitated treatment adherence, facilitated collaborative goal setting, and supported the optimization of rehabilitation strategies tailored to patient characteristics. These findings suggest the potential value of integrating digital health technologies into conventional lymphedema management; this requires cautious interpretation and further validation through larger, controlled studies.

Funding

None.

Conflict of interest

The authors declare no conflict of interest.