Unveiling kinesiophobia: A hidden challenge in women with lipedema

Abstract

Background

To evaluate kinesiophobia and its relationship with disease-related characteristics and quality of life in lipedema patients.

Methods

In this descriptive case-control study, 40 lipedema patients and 40 participants in the control group were included. All participants were evaluated in terms of body mass index (BMI), pain numeric rating scale (NRS) and pain threshold (PT) scores, kinesiophobia (Tampa Scale for Kinesiophobia - TSK), lower extremity functional scores (Lower Extremity Functional Scale - LEFS), and health-related quality of life (Nottingham Health Profile - NHP) scores. Additionally, the lipedema patients were evaluated in terms of extremity volumes, and total and mean lower extremity fat mass by dual-energy X-ray absorptiometry.

Results

High kinesiophobia was detected in 78% of the lipedema patients and 55% of the control group (p = .033). TSK (p = .048), NRS (p = .001), and NHP total scores (p = .041) were higher and PT scores (p = .007) were lower in lipedema patients compared to the control group. No difference was found between lipedema patients with high and low kinesiophobia in terms of fat mass or extremity volumes. A positive correlation was found between TSK score, NHP total score (r = 0.356, p = .024), NHP physical activity (ρ = 0.403, p = .010) and NHP energy (ρ = 0.436, p = .005) subscale scores.

Conclusion

Kinesiophobia is highly prevalent in lipedema patients, regardless of disease-related data and affecting the quality of life of the patients, negatively.

Keywords

Lipedema kinesiophobia pain quality of life

Introduction

Lipedema is a persistent and frequently progressive disorder that is characterized by symmetrical enlargement, pain, and easy bruising in the lower and/or upper limbs. The body type is disease-specific and resistant to excessive exercise and diet. Although there are several hypotheses, including genetic, hormonal, vascular, and lymphatic factors, the pathophysiology of the disease and the mechanism of the pain are still unclear.^1,2 Since lipedema is frequently unrecognized, failing to lose weight and feeling chronic pain lead to poor quality of life and psychological problems, such as depression, anxiety, and bulimia nervosa.^3,4 Limited limb mobility and pain are the factors that can contribute to health-related quality of life deficiencies.⁵

Kinesiophobia is defined as an excessive and irrational fear of physical movement to avoid harm or re-injury. It can also be defined as an excessive irrational fear of physical movement and activity resulting from a feeling of vulnerability due to pain. It appears as a type of fear avoidance behavior.^6,7 It has been shown that kinesiophobia is more common in diseases affecting the lower extremities such as obesity,⁸ knee osteoarthritis,⁹ and lymphedema.^10,11 Since lipedema is a chronic disorder characterized by pain in lower extremities, it was hypothesized that kinesiophobia could be seen more frequently in lipedema patients than in the healthy population. Therefore, it was aimed to examine lipedema patients in terms of kinesiophobia, compare them to the control group, compare the lipedema patients with low and high kinesiophobia in terms of disease-related data and to evaluate the correlation between lipedema disease-related data and kinesiophobia.

Material and method

The study was conducted in accordance with the Declaration of Helsinki and approved by the ethics committee. Written informed consent was obtained from all participants.

This descriptive case–control study was conducted in a tertiary hospital. Individuals who applied to the Physical Medicine and Rehabilitation clinic and met the terms of inclusion and exclusion criteria were included between January 2024 and June 2024.

Women with lipedema, aged 18 and over were included in the study. The patients in the lipedema group had no history of liposuction surgery, musculoskeletal/vestibular disease, heart failure, hypothyroidism, no active infection, peripheral vascular disease or cancer. The participants in the control group had no history of systemic, neuromusculoskeletal or vestibular disease. Furthermore, the control group was matched to the lipedema group in terms of age and body mass index (BMI) to ensure comparability between groups. The control group was not selected from hospital patients. Instead, it primarily comprised healthcare professionals and family members accompanying patients without lipedema. This approach was adopted to ensure ease of recruitment.

In this study, lipedema diagnosis was confirmed based on clinical criteria proposed by Wold et al.¹² According to these criteria, the expansion starting from the hips and lower extremities progresses symmetrically bilaterally. Feet generally maintain their normal size and structure. There is moderate to severe sensitivity to digital pressure. Subcutaneous fat tissue is soft and flexible. Usually, the upper body parts are normal in size. There are 5 types and 4 stages of lipedema.¹³ Fat accumulation is around the hips and buttocks in type 1, extends from the hips to the knee in type 2, extends from the hips to the ankle in type 3, and if the arms are also involved, it is defined as type 4. In type 5, fat accumulation occurs predominantly only in the calf area. In stage 1, the skin is smooth and soft, but the underlying hypodermis is thickened on palpation. In stage 2, there is a nodular appearance on the skin that resembles orange peel skin. In stage 3, there are large folds and pits on the deformed fat masses. If lymphedema accompanies lipedema, it is considered stage 4. In the present study, participants were eligible if they were diagnosed with lipedema of type 2 or type 3 and classified as stage 1, 2, or 3.

Patients with a diagnosis of lipedema were evaluated by a physical medicine and rehabilitation physician who recorded sociodemographic data, BMI, pain numeric rating scale (NRS) and pain threshold (PT) scores, extremity volumes, total and mean lower extremity fat mass, kinesiophobia (Tampa Scale for Kinesiophobia - TSK), lower extremity functional scores (Lower Extremity Functional Scale - LEFS) and health related quality of life (Nottingham Health Profile - NHP) scores. In the control group, BMI, NRS, PT, TSK, LEFS, and NHP scores were recorded.

Patients with lipedema were compared with the control group in terms of age, BMI, pain and pain threshold, TSK, LEFS, NHP scores. Then the lipedema group was divided into two groups, those with low and high kinesiophobia, and these two subgroups were compared in terms of age, BMI, extremity volumes, total and mean lower extremity fat mass, pain and pain threshold, TSK, LEFS, NHP scores. Additionally, correlation analyses were conducted within lipedema group to examine associations between TSK scores and each of the following variables: age, BMI, extremity volumes, total and mean lower extremity fat mass, pain and pain threshold, LEFS, and NHP scores.

Outcome measures

• Numeric Rating Scale (NRS) was used for evaluation of pain intensity. Patients were required to rate their pain out of 10: 0 corresponds to no pain, while 10 indicates the worst pain.¹⁴

• Algometric measurements were performed to determine pain threshold (PT). Before the evaluation, patients were informed about how the measurement would be performed. The probe of the algometer device was held perpendicular to the measured surface and the compression applied was gradually increased at a rate of approximately 0.5 kg/cm²/s. Patients were asked to provide information as soon as the feeling of pressure turned into a feeling of pain and this value was recorded. After a 4-min break, a second measurement was made from the same area, and the average of these two measurements was recorded as the PT for that extremity.¹⁵ The average PT value was obtained by taking the average of the PT assessments of both lower extremities.

• For the lower extremity volume measurements of the patients, circumference measurements were taken from the ankle to the groin at 4 cm intervals; these values were recorded in the Excel program and limb volumes were automatically calculated with the Pythagorean theorem.

• Dual-energy X-Ray Absorptiometry (DXA) measurements were performed with the patient in the supine position at head-heel distance with a radiation dose of 5.08 μSv, voltage of 83.00 Kv, and current of 0.2 mA (Primus, X-ray densitometer, Osteosys Co. Ltd., Guro-gu, Seoul, Korea). Fat mass and lower extremity fat mass were calculated from the obtained values using Osteosys Primus version 1.2.0 software.

• Tampa Scale for Kinesiophobia (TSK) was used to evaluate kinesiophobia. The scale consisting of 17 questions is developed to measure fear of movement and re-injury. Each item is evaluated out of 4 points. Patients can be given a minimum score of 17 and a maximum score of 68 points. A high score on the scale indicates high kinesiophobia.^16,17 In this study, scores above 37 were classified as high kinesiophobia, while scores of 37 and below as low kinesiophobia.¹⁸

• Lower Extremity Functional Scale (LEFS) was used to evaluate the lower extremity functions, abilities and activity limitations of the participants.^19,20

• Nottingham Health Profile (NHP) was used to evaluate patients’ perception of health problems and the impact of these problems on patients’ daily living activities. Pain, emotional reactions, sleep, social isolation, physical activity, and energy subscales are evaluated. A higher score indicates a worse quality of life.^21,22

Sample size

G*Power (V3.1) software (Informer Technologies, Inc., Los Angeles, USA) was used to calculate the required sample size. Using data from a previous study, the effect size in our sample size calculation was found to be 0.64. Based on a power of 80% and a 5% level of significance, the total sample size required was calculated as 80.²³

Statistical analysis

Statistical analyses were conducted using SPSS version 23.0 software (IBM Corporation, Armonk, NY, USA). Continuous data were presented as mean ± standard deviation (SD) and median (interquartile range), while categorical variables were expressed as numbers and percentages. The normality of the data distribution was evaluated with the Kolmogorov-Smirnov test. Depending on the normality of the variables, comparisons between groups were performed using either the independent samples t-test or the Mann-Whitney U test. Categorical variables were analyzed using Pearson’s chi-square test. Correlations among quantitative variables were assessed using Pearson or Spearman correlation coefficients. A p-value of less than 0.05 was considered statistically significant.

Results

A total of 80 participants were included in the study, 40 lipedema patients and 40 controls matched for age and BMI. High kinesiophobia was detected in 78% of the lipedema patients (n = 31) and 55% of the control group (n = 22), and this difference was statistically significant (p = .033, Figure 1).

Figure 1.

High and low kinesiophobia percentages of the groups (p = .033).

Demographic data, pain-related scores, and comparison of TSK for kinesiophobia between the lipedema and control groups are summarized in Table 1. TSK scores (p = .048), NRS scores (p = .001), and NHP total scores (p = .041) were found to be statistically significantly higher in lipedema patients, while PT scores (p = .007) were found to be statistically significantly lower. However, no significant difference was found between the groups in terms of LEFS scores (p > .05).

Table 1.

Comparisons between lipedema and group.

	Lipedema group (n = 40)		Control group (n = 40)		p
	Mean ± SD	Median (IR)	Mean ± SD	Median (IR)
Age (years)	41.90 ± 11.55	14.50 (19.00)	42.35 ± 12.85	41.00 (19.00)	0.870^t
BMI (kg/m ² )	31.95 ± 6.76	32.17 (10.13)	29.64 ± 6.82	29.51 (9.23)	0.132^t
TSK	41.60 ± 5.85	41.50 (7.00)	38.47 ± 7.89	39.00 (9.75)	0.048 ^t *
NRS	5.77 ± 2.06	6.00 (2.00)	3.95 ± 2.36	4.00 (3.75)	0.001 ^m **
PT (kg/cm ² )	6.37 ± 8.26	3.47 (1.70)	4.63 ± 1.17	4.57 (1.55)	0.007 ^m **
LEFS	54.35 ± 16.39	56.50 (24.75)	59.32 ± 20.56	67.00 (32.00)	0.061^m
NHP total	211.71 ± 115.60	207.66 (161.33)	152.40 ± 138.50	115.44 (192.64)	0.041 ^t *
Pain	49.74 ± 29.47	38.92 (48.58)	27.67 ± 29.97	17.63 (44.60)	<0.001 ^m ***
Emotion	29.47 ± 29.04	25.55 (51.17)	26.70 ± 29.53	17.55 (43.32)	0.615^m
Sleep	27.21 ± 22.33	27.26 (27.26)	18.37 ± 27.57	0.00 (39.83)	0.018 ^m *
Social	19.35 ± 28.35	0.00 (41.23)	14.32 ± 24.94	0.00 (21.54)	0.446^m
Physical activity	27.90 ± 21.05	21.99 (33.70)	19.01 ± 19.82	11.54 (32.56)	0.059^m
Energy	58.02 ± 38.74	63.20 (72.80)	46.36 ± 39.78	39.25 (94.00)	0.158^m

SD , standard deviation; IR, interquartile range; BMI , body mass index; TSK , tampa scale for kinesiophobia; NRS , numeric rating scale; PT , pain threshold; LEFS , lower extremity functional scale; NHP , nottingham health profile; t , Student's t-test; m , Mann-Whitney U test.

The comparison of lipedema patients with high and low kinesiophobia is shown in Table 2. No statistically significant difference was found between the two groups in terms of age, BMI, total fat mass (Total FM), mean lower extremity fat mass (MLEFM), mean lower extremity volume (MLEV), NRS, PT, LEFS, and NHP total score (p > .05). Only NHP energy subscale score was found to be significantly higher in patients with high kinesiophobia (p = .003).

Table 2.

Comparisons of lipedema patients regarding the kinesiophobia levels.

	Lipedema patients with low kinesiophobia (n = 9)		Lipedema patients with high kinesiophobia (n = 31)
	Mean ± SD	Median (IR)	Mean ± SD	Median (IR)	p
Age (years)	41.44 ± 9.15	41.00 (14.50)	42.03 ± 12.28	41.00 (14.50)	0.895^t
BMI (kg/m ² )	29.93 ± 7.63	27.30 (14.30)	32.54 ± 6.50	32.79 (9.30)	0.313^t
Total FM (kg)	35.37 ±15.07	27.62 (21.56)	36.75 ± 11.41	37.91 (15.16)	0.768^t
MLEFM (kg)	7.86 ± 2.92	6.16 (4.68)	7.99 ± 2.14	8.13 (2.96)	0.679^m
MLEV (L)	11.81 ± 3.67	10.12 (6.58)	12.01 ± 2.38	11.80 (2.83)	0.884^t
NRS	6.22 ± 1.56	7.00 (2.00)	5.64 ± 2.19	6.00 (4.00)	0.503^m
PT (kg/cm ² )	5.52 ± 4.38	3.85 (1.75)	6.61 ± 9.13	3.35 (1.60)	0.099^m
LEFS	57.00 ± 13.36	56.00 (19.50)	53.58 ± 17.29	57.00 (27.00)	0.702^m
NHP total	151.74 ± 105.09	131.56 (113.28)	229.13 ± 114.16	215.53 (144.91)	0.059^m
Pain	45.41 ± 33.05	37.69 (64.00)	51.00 ± 28.82	38.92 (43.14)	0.406^m
Emotion	17.77 ± 25.51	10.47 (25.21)	32.87 ± 29.50	34.18 (55.25)	0.262^m
Sleep	25.46 ± 9.53	27.26 (15.65)	27.73 ± 24.96	27.26 (43.36)	0.682^t
Social	24.67 ± 39.25	0.00 (53.02)	17.81 ± 24.98	0.00 (42.14)	0.775^m
Physical activity	15.95 ± 19.05	11.54 (27.76)	31.38 ± 20.60	22.74 (23.34)	0.055^m
Energy	22.49 ± 33.72	0.00 (39.20)	68.34 ± 34.05	63.20 (39.20)	0.003 ^m **

SD , standard deviation; IR, interquartile range; BMI , body mass index; FM , fat mass; MLEFM , mean lower extremity fat mass; MLEV , mean lower extremity volume; NRS , numeric rating scale; PT , pain threshold; LEFS , Lower Extremity Functional Scale; NHP , Nottingham Health Profile; t , Student's t-test; m , Mann-Whitney U test.

Correlation analysis between TSK scores and other data in lipedema patients is summarized in Table 3. As a result of the analysis, a low-level positive correlation was found between TSK score and NHP total score (r = 0.356, p = .024). In particular, physical activity (ρ = 0.403, p = .010) and energy (ρ = 0.436, p = .005) subscale scores were found to have a significant correlation with TSK score.

Table 3.

Correlation analysis between TSK scores and other disease-related scores in the lipedema paitents (n = 40).

	TSK	p
Age	0.136^r	0.402
BMI	0.224 ^r	0.165
Total FM	0.076 ^r	0.643
MLEFM)	0.078 ^r	0.643
MLEV	0.051 ^r	0.752
NRS	−0.009 ^ρ	0.956
PT	0.053 ^ρ	0.745
LEFS	−0.199 ^ρ	0.218
NHP total	0.356 ^r	0.024*
Pain	0.122 ^ρ	0.454
Emotion	0.251 ^ρ	0.118
Sleep	0.188 ^r	0.246
Social	0.037 ^ρ	0.820
Physical activity	0.403 ^ρ	0.010*
Energy	0.436 ^ρ	0.005**

r, Pearson correlation; ρ, (rho) Spearman correlation; BMI , body mass index; FM , fat mass; MLEFM , mean lower extremity fat mass; MLEV , mean lower extremity volume; NRS , numeric rating scale; PT , pain threshold; LEFS , Lower Extremity Functional Scale; NHP , Nottingham Health Profile.

Discussion

To the best of our knowledge, this is the first study evaluating kinesiophobia in patients with lipedema. The hypothesis of the study was that kinesiophobia would be higher in the lipedema patients than in the control group, and that kinesiophobia would be related to high fat mass and extremity volumes. The results of the study partially supported this hypothesis. The TSK scores of patients in the lipedema group were higher than those in the control group and the number of patients with high kinesiophobia was statistically significantly higher in the lipedema group. In addition, pain scores were higher, pain threshold and pain-related quality of life were lower in the lipedema patients than in the control group.

It is known that pain is the primary complaint in lipedema.²⁴ In addition to the painful nature of lipedema fat, the negative effects of the disease-specific body structure on the lower extremity joints and spine also contribute to pain.²⁵ In the present study, high pain levels and low pain thresholds were to be probably the most important causes of kinesiophobia. Furthermore, lipedema is characterized by the failure of extreme diets and physical activity to reduce fat accumulation.²⁶ Unsuccessful exercise experiences throughout life may also contribute to the development of kinesiophobia.

Previous studies have stated that obesity is a risk factor for kinesiophobia.^8,27,28 However, since the BMIs of the lipedema and control groups were similar, the findings of this study suggest that kinesiophobia in lipedema patients cannot be solely attributed to a high BMI. Although the rate of kinesiophobia was relatively high in the control group- possibly due to obesity- it was significantly more common in the lipedema group (77.5%) compared to the control group (55.0%). Moreover, the absence of a correlation between TSK scores and BMI in the lipedema group further supports this finding. On the other hand, the high prevalence of kinesiophobia observed in the control group was also unexpected. Since the study was conducted in a tertiary hospital setting, a substantial proportion of the control participants were healthcare professionals and family members accompanying patients. It is therefore plausible that exposure to a high-stress clinical environment and emotional concerns related to caregiving may have contributed to elevated levels of anxiety and stress, thereby influencing their kinesiophobia scores. This recruitment strategy was adopted to facilitate accessibility; however, the unique background of the control participants may have influenced certain psychosocial variables, such as work-related stress, emotional burden from caregiving, or heightened sensitivity to health-related symptoms, potentially limiting the generalizability of the findings.

From another perspective, the humiliation and shame that lipedema patients experience may contribute to increased kinesiophobia levels. As shown in the study conducted by Melander et al, these women are humiliated because they are perceived as “fat” and seen as “characterless” by others since they cannot control their bodies.²⁹ Over the years, they may internalize these humiliations, and the resulting distortion of self-perception may cause them to become ashamed of their bodies. This social experience may lead them to avoid movement in order not to be noticed and thus avoid being judged and humiliated by others. For this reason, it can be considered that these psychosocial factors may be among the reasons for the increased kinesiophobia observed in patients with lipedema.

When patients with high and low kinesiophobia were compared within the lipedema group, there was no significant differences were in disease-related measurements (pain threshold, total and lower extremity fat mass, and extremity volumes). This suggests that kinesiophobia emerges regardless of the severity of lipedema. DXA was used for fat measurement in the study. DXA is a preferred and useful method in the diagnosis and follow-up of lipedema.^30,31 However, its major disadvantage is its inability to differentiate between fat and water.³² Therefore, further studies using methods that allow high-quality evaluation of soft tissue, such as MRI, may provide more definitive results.

In the evaluation of the lipedema group, no correlation was found between TSK scores and BMI, pain, lower extremity function, fat mass, or lower extremity volumes. Unfortunately, these results didn’t support the hypothesis of the present study. It was slightly surprising that TSK scores did nor correlate with disease-related variables, since considering that the main pathology in lipedema is hypertrophic, fibrotic and inflamed adipose tissue.^33,34 Although the sample size was determined through a power analysis based on a previous study, it is believed that this relationship could be evaluated more thoroughly in larger future studies.

Another important finding of this study was the significant correlation between kinesiophobia scores and NHP scores, suggesting that kinesiophobia is associated with a worse overall quality of life. In particular, the life domains of energy and physical activity were negatively affected. Similarly, in a previous study it is reported that pain and low physical activity levels negatively affect overall health.³⁵ In order to improve the quality of life of lipedema patients, beyond the commonly suggested interventions such as physical exercise,³⁶ diet-induced weight loss,³⁷ decongestive therapies,^38,39 treatment for fibromyalgia symptoms,^40,41 and even surgery,⁴² it is important to provide medical support specifically targeting kinesiophobia.

Lipo-lymphedema (stage 4 lipedema) patients were not included in this study. However, it is known that even in early stages, interstitial fluid accumulation increases in lipedema patients.⁴³ Potential contributing factors promoting fluid accumulation in lipedema include increased limb capillary pressure, tissue structural alterations, impaired vascular permeability, increased lymphatic area, and insufficient lymphatic outflow.⁴⁴ As in lymphedema,^10,11 where interstitial fluid increases due to lymphatic drainage disorders, kinesiophobia was found to be high in lipedema patients in this study.

In conclusion, kinesiophobia is highly prevalent in lipedema, regardless of disease-related factors. Considering that achieving a normal BMI, and engaging in exercise are recommended as the first-line treatments for lipedema, avoidance of movement due to kinesiophobia could negatively impact treatment success. If kinesiophobia is not addressed, patients may find themselves in a vicious circle: they avoid movement due to kinesiophobia, treatment is hindered due to lack of movement, and worsening symptoms further reinforce the fear of movement. To break this cycle, kinesiophobia must be recognized and managed. Given its high prevalence and detrimental impact on quality of life, kinesiophobia should be routinely assessed in individuals with lipedema and effectively addressed through targeted interventions to enhance treatment outcomes and overall well-being.

Footnotes

Authors’ note

The author (Mihrinur Dilvin Türköz) has moved to ‘Giresun Physical Therapy and Rehabilitation Centre, Giresun, Turkey’ since completing the research.

Author contributions

Conceptualization: ZK, MDT, BK, NÇY. Data curation: ZK, MDT, BK. Analysis: ZK, BK. Investigation: ZK. Methodology: ZK, MDT. Software: ZK, MDT. Visualization: ZK, NÇY. Writing - original draft: ZK. Writing - review & editing: ZK, MDT, BK, NÇY.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

The study was approved by the Ethics Committee of Giresun Education and Research Hospital (approval no: 18.12.2023/11). Also, the study was performed according to the Helsinki Guidelines.

Informed consent

A written informed consent was obtained from each patient.

Guarantor

ORCID iDs

Zerrin Kasap

Mihrinur Dilvin Türköz

Benay Keleş

Nurçe Çilesizoğlu Yavuz

Data Availability Statement

The datasets analysed during the current study are not publicly available due to the privacy of subjects but are available from the corresponding author on reasonable request.*

References

Aksoy

Karadag

Wollina

. Cause and management of lipedema-associated pain. Dermatol Ther 2021; 34: e14364.

Szél

Kemény

Groma

, et al. Pathophysiological dilemmas of lipedema. Med Hypotheses 2014; 83: 599–606.

Fife

Maus

Carter

. Lipedema: a frequently misdiagnosed and misunderstood fatty deposition syndrome. Adv Skin Wound Care 2010; 23: 81–92.

Dudek

Białaszek

Gabriel

. Quality of life, its factors, and sociodemographic characteristics of Polish women with lipedema. BMC Womens Health 2021; 21: 1–9.

Alwardat

Di Renzo

Alwardat

, et al. The effect of lipedema on health-related quality of life and psychological status: a narrative review of the literature. Eat Weight Disord 2020; 25: 851–856.

Vlaeyen

Kole-Snijders

Boeren

, et al. Fear of movement/(re) injury in chronic low back pain and its relation to behavioral performance. Pain 1995; 62: 363–372.

Roelofs

Van Breukelen

Sluiter

, et al. Norming of the Tampa Scale for Kinesiophobia across pain diagnoses and various countries. Pain 2011; 152: 1090–1095.

Ercan

Kucuk

Orscelik

, et al. Musculoskeletal pain, kinesiophobia, and quality of life in obese patients. Eur J Res 2023; 9: 665–673.

Durna

Vergili

Fidancı

. Pain, kinesiophobia, functional status, and physical activity among patients with knee osteoarthritis. J Orthop Res Rehabil 2023; 1: 32–36.

10.

Pirincci

Cihan

Ünüvar

, et al. Investigation of physical activity, fear of falling, and functionality in individuals with lower extremity lymphedema. Support Care Cancer 2023; 31: 360.

11.

Monteiro

de Labra

Losa-Iglesias

, et al. The relationship of kinesiophobia in patients with lymphedema: a case-control investigation. Front Psychiatry 2024; 15: 1293614.

12.

Wold

Hines

Allen

. Lipedema of the legs: a syndrome characterized by fat legs and edema. Ann Intern Med 1951; 34: 1243–1250.

13.

Buso

Favre

Vionnet

, et al. Body composition assessment by dual-energy X-ray absorptiometry: a useful tool for the diagnosis of lipedema. Obesity Facts 2022; 15(6): 762–773.

14.

Hjermstad

Fayers

Haugen

, et al. Studies comparing numerical rating scales, verbal rating scales, and visual analogue scales for assessment of pain intensity in adults: a systematic literature review. J Pain Symptom Manage 2011; 41: 1073–1093.

15.

Sanches

Juliano

Novo

, et al. Correlation between pressure pain threshold and pain intensity in patients with temporomandibular disorders who are compliant or non-compliant with conservative treatment. Oral Surg Oral Med Oral Pathol Oral Radiol 2015; 120: 459–468.

16.

Kinesiophobia

SHK

. A new view of chronic pain behavior. Pain Manag 1990; 3: 35–43.

17.

Yilmaz

ÖT

Yakut

Uygur

, et al. Tampa Kinezyofobi Ölçeği’nin Türkçe versiyonu ve test-tekrar test güvenirliği. Fizyoterapi Rehabilitasyon 2011; 22: 44–49.

18.

Sari

Tatli

Ilhanli

, et al. Spinal mobility limitation can Be the main reason of kinesiophobia in ankylosing spondylitis. Cureus 2023; 15: e42528.

19.

Çankaya

. Alt eksremite fonksiyonel ölçeğinin türkçe geçerlilik ve güvenilirlik çalışması. 2016.

20.

Binkley

Stratford

Lott

, et al. The lower extremity functional scale (LEFS): scale development, measurement properties, and clinical application. North American orthopaedic rehabilitation research network. Phys Ther 1999; 79: 371–383.

21.

Kücükdeveci

McKenna

Kutlay

, et al. The development and psychometric assessment of the Turkish version of the Nottingham Health Profile. Int J Rehabil Res 2000; 23: 31–38.

22.

Essink-Bot

M-L

Krabbe

Bonsel

, et al. An empirical comparison of four generic health status measures: the Nottingham health profile, the medical outcomes study 36-item short-form health survey, the COOP/WONCA charts, and the EuroQol instrument. Med Care 1997; 35: 522–537.

23.

Özcan

Kalem Özgen

Örücü Atar

, et al. Fibromiyalji sendromlu hastalarda kinezyofobiyi etkileyen faktörler ve kinezyofobinin tedaviye uyum sürecine etkisi. J Phys Med Rehabil Sci 2022; 25: 213–219.

24.

Romeijn

de Rooij

Janssen

, et al. Exploration of patient characteristics and quality of life in patients with lipoedema using a survey. Dermatol Ther 2018; 8: 303–311.

25.

Torre

YSD

Wadeea

Rosas

, et al. Lipedema: friend and foe. Horm Mol Biol Clin Invest 2018; 33: 1–10.

26.

Herbst

Kahn

Iker

, et al. Standard of care for lipedema in the United States. Phlebology 2021; 36: 779–796.

27.

Vincent

Lamb

Day

, et al. Morbid obesity is associated with fear of movement and lower quality of life in patients with knee pain-related diagnoses. PM&R 2010; 2: 713–722.

28.

Vincent

Seay

Montero

, et al. Kinesiophobia and fear-avoidance beliefs in overweight older adults with chronic low-back pain: relationship to walking endurance—part II. Am J Phys Med Rehabil 2013; 92: 439–445.

29.

Melander

Juuso

Olsson

. Women’s experiences of living with lipedema. Health Care Women Int 2022; 43: 54–69.

30.

Dietzel

Reisshauer

Jahr

, et al. Body composition in lipoedema of the legs using dual-energy X-ray absorptiometry: a case–control study. Br J Dermatol 2015; 173: 594–596.

31.

Buso

Favre

Vionnet

, et al. Body composition assessment by dual-energy x-ray absorptiometry: a useful tool for the diagnosis of lipedema. Obes Facts 2022; 15: 762–773.

32.

van la Parra

Deconinck

Krug

. Diagnostic imaging in lipedema: a systematic review. Obes Rev 2024; 25: e13648.

33.

Felmerer

Stylianaki

Hägerling

, et al. Adipose tissue hypertrophy, an aberrant biochemical profile and distinct gene expression in lipedema. J Surg Res 2020; 253: 294–303.

34.

Kruppa

Gohlke

Łapiński

, et al. Lipedema stage affects adipocyte hypertrophy, subcutaneous adipose tissue inflammation and interstitial fibrosis. Front Immunol 2023; 14: 1223264.

35.

Aitzetmüller-Klietz

M-L

Busch

Hamatschek

, et al. Understanding the vicious circle of pain, physical activity, and mental health in lipedema patients—a response surface analysis. J Clin Med 2023; 12: 5319.

36.

Annunziata

Paoli

Manzi

, et al. The Role of Physical Exercise as a Therapeutic Tool to Improve Lipedema: A Consensus Statement from the Italian Society of Motor and Sports Sciences (Società Italiana di Scienze Motorie e Sportive, SISMeS) and the Italian Society of Phlebology (Società Italiana di Flebologia, SIF). Curr Obes Rep 2024; 13(4): 667–679.

37.

Lundanes

Sandnes

Gjeilo

, et al. Effect of a low-carbohydrate diet on pain and quality of life in female patients with lipedema: a randomized controlled trial. Obesity 2024; 32: 1071–1082.

38.

Wright

Scarfino

O’Malley

. Effect of pneumatic compression device and stocking use on symptoms and quality of life in women with lipedema: a proof-in-principle randomized trial. Phlebology 2023; 38: 51–61.

39.

Czerwińska

Gruszecki

Rumiński

, et al. Evaluation of the effectiveness of compression Therapy combined with exercises versus exercises only among lipedema patients using various outcome measures. Life 2024; 14: 1346.

40.

Cagliyan Turk

Erden

Eker Buyuksireci

, et al. Prevalence of fibromyalgia syndrome in women with lipedema and its effect on anxiety, depression, and quality of life. Lymphat Res Biol 2024; 22: 2–7.

41.

Çakıt

Atar

Ayaz

, et al. Comorbidity of lipedema and fibromyalgia; effects on disease severity, pain and health-related quality of life. J Med Palliat Care 2023; 4: 234–240.

42.

Wright

Babula

Schwartz

, et al. Lipedema reduction surgery improves pain, mobility, physical function, and quality of life: case series report. Plast Reconstr Surg Glob Open 2023; 11: e5436.

43.

Poojari

Dev

Rabiee

. Lipedema: insights into morphology, pathophysiology, and challenges. Biomedicines 2022; 10: 3081.

44.

Allen

Schwartz

Herbst

. Interstitial fluid in lipedema and control skin. Womens Health Rep 2020; 1: 480–487.