Effectiveness of a Tele-Rehabilitation-Based Exercise and Self-Lymphatic Drainage Program Supported by Self-Management for Breast Cancer-Related Lymphedema

• Tele-rehabilitation-Based Exercise and Self-Lymphatic Drainage Program (Other): The exercise and self-lymphatic drainage program will be performed under live online supervision.
• Home-Based Exercise and Self-Lymphatic Drainage Program (Other): The same exercise and self-lymphatic drainage program will be performed at home using an educational brochure.

Primary outcomes

• Change from Baseline in Affected Upper Extremity Volume [Baseline (before starting treatment), Week 8 (end of intervention), Week 12 (one month after the end of intervention)]: Limb volume is an objective measure used to evaluate swelling associated with upper extremity lymphedema. Bilateral arm circumference measurements will be obtained using a low-stretch measuring tape at six reference points: the metacarpophalangeal joint, wrist joint, 10 and 15 cm distal to the lateral epicondyle, and 10 and 15 cm proximal to the lateral epicondyle. Bilateral upper limb volume will be calculated indirectly using the truncated cone formula. The change from baseline in affected upper extremity volume will be evaluated as the primary outcome. Treatment response will additionally be assessed using the excess volume difference between the affected and unaffected limbs and the percentage change in excess volume (PCEV). Lymphedema severity will also be classified according to the excess limb volume difference as minimal (5-<20% increase), moderate (20-40% increase), and severe (>40% increase).

Secondary outcomes

• Lymphedema Stage [Baseline (before starting treatment), Week 8 (end of intervention), and Week 12 (one month after the end of intervention)]: Lymphedema stage will be assessed according to the International Society of Lymphology (ISL) classification system. The ISL classification categorizes lymphedema severity into stages 0, I, II, and III based on clinical findings. Stage 0 represents a latent or subclinical condition without evident swelling despite impaired lymphatic transport. Stage I is characterized by early fluid accumulation that decreases with limb elevation and may include pitting edema. Stage II involves persistent swelling with tissue changes, including fibrosis and fat deposition, with limited response to elevation. Stage III represents advanced lymphedema with marked swelling, fibrosis, fat deposition, and skin changes.
• Visual Analog Scale (VAS) for Lymphedema Symptom Severity [Baseline (before starting treatment), Week 8 (end of intervention), and Week 12 (one month after the end of intervention]: The Visual Analog Scale (VAS) is a commonly used assessment tool for measuring symptom intensity. Lymphedema symptom severity will be assessed using the VAS, a simple and reproducible tool used to evaluate the intensity of subjective symptoms. Participants will rate the severity of lymphedema-related symptoms, including fullness/tightness, heaviness, swelling, and pain in the affected extremity, on a 10-cm horizontal scale. The scale ranges from 0 (no symptom) to 10 (the most severe symptom). Higher scores indicate greater symptom severity.
• Hand Grip Strength [Baseline (before starting treatment), Week 8 (end of intervention), and Week 12 (one month after the end of intervention)]: Hand grip strength will be assessed using the Jamar hydraulic hand dynamometer, a commonly used and reliable tool for evaluating maximal grip force. Participants will be seated upright with back support, hips and knees flexed at 90°, feet supported on the floor, shoulder adducted, elbow flexed at 90°, and wrist positioned in 15°-30° extension and 0°-15° ulnar deviation. After demonstration of the measurement procedure, participants will be instructed to squeeze the dynamometer maximally for 3 seconds. Three measurements will be performed with 1-minute intervals, and the mean value will be recorded in kg/f.
• Quick Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH) [Baseline (before starting treatment), Week 8 (end of intervention), and Week 12 (one month after the end of intervention)]: The Quick Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH) is a self-reported questionnaire used to assess upper extremity function, disability, and symptoms. The questionnaire consists of 11 items evaluating difficulty during physical activities, the impact of upper extremity problems on daily and social activities, sleep, pain, and numbness. Each item is scored from 1 to 5, and the total score is converted to a scale ranging from 0 to 100. Higher scores indicate greater disability and more severe upper extremity impairment.
• Lymphedema Quality of Life Questionnaire - Arm (LYMQOL-Arm) [Baseline (before starting treatment), Week 8 (end of intervention), and Week 12 (one month after the end of intervention)]: The Lymphedema Quality of Life Questionnaire - Arm (LYMQOL-Arm) is a disease-specific questionnaire developed to assess quality of life in individuals with upper extremity lymphedema. The questionnaire consists of four domains, including function, appearance/body image, symptoms, and mood, as well as one overall quality of life item. Each domain item is rated on a 4-point Likert scale (1 = not at all, 4 = very much), with higher scores indicating poorer quality of life. The overall quality of life item is rated on a scale from 0 (worst quality of life) to 10 (best quality of life). Mean scores are calculated for each domain, and domain scores together with the overall quality of life score are used for evaluation.
• Breast Cancer-Related Lymphedema Self-Care Scale [Baseline (before starting treatment), Week 8 (end of intervention), and Week 12 (one month after the end of intervention)]: The Breast Cancer-Related Lymphedema Self-Care Scale is a questionnaire developed to assess self-care behaviors in individuals with breast cancer-related lymphedema. The scale consists of 31 items and four subdomains, which are rated using a 4-point Likert scale. Total scores range from 31 to 124, with higher scores indicating better self-care practices.
• Lymphedema Self-Management Adherence Monitoring Form [From baseline to Week 12 (during the 8-week intervention period and 4-week follow-up period)]: The Lymphedema Self-Management Adherence Monitoring Form is a daily tracking form developed to evaluate participants' adherence to self-management practices, including exercise, self-lymphatic drainage (SLD), and compression garment use. Participants will record whether they performed the exercise and SLD program, as well as the duration and number of sessions. Compression garment use will be recorded based on daily usage and duration of wear (hours). Adherence will be evaluated based on data collected throughout the 8-week intervention period and the subsequent 4-week follow-up period.
• Patient Satisfaction with Tele-rehabilitation Program [Week 8 (end of intervention)]: Patient satisfaction with the tele-rehabilitation program will be assessed using a single-item 0-10 satisfaction rating scale developed by the researchers. Participants will rate their overall satisfaction with the tele-rehabilitation program from 0 (not satisfied at all) to 10 (completely satisfied). Higher scores indicate greater satisfaction.

Sex: Female, ages: 20 Years to 65 Years

Inclusion Criteria

* Female participants between 20 and 65 years of age
* History of unilateral breast cancer surgery including axillary lymph node dissection
* Completion of breast cancer treatments, including surgery, radiotherapy, and chemotherapy, with at least 3 months elapsed since treatment completion
* Diagnosis of stage I or stage II upper extremity lymphedema according to the International Society of Lymphology (ISL) classification
* Presence of at least 5% volume difference between the affected and unaffected upper extremities
* No history of manual lymphatic drainage, compression bandaging treatment, or structured resistance exercise program within the previous 3 months
* Ability to use a smartphone or tablet and sufficient cognitive and motor ability to participate in digital sessions
* Prescription of an appropriate compression garment for the affected extremity and regular use of the garment as recommended

Exclusion Criteria

* Presence of uncontrolled hypertension, pulmonary edema, or severe cardiovascular disease
* Presence of psychiatric or cognitive impairment that may interfere with study participation or adherence
* Presence of stage III lymphedema according to the ISL classification
* Presence of skin lesions such as papilloma or hyperkeratosis in the lymphedematous area
* History of bilateral breast cancer
* Presence of active cancer or clinical/radiological evidence of metastasis
* Presence of active infection in the affected extremity