Table 1 Template for intervention description and replication (TIDieR) checklist.

The name of the intervention

A multimodal physical therapy approach comprising MLD, IPC, compression garments, exercises (along with compression garments), and meticulous skin care.

Rationale

• MLD stimulates lymph flow, generates new lymphatic channels, and softens fibrotic tissue.

• IPC forces tissue fluid to areas where lymphatic outflow is typical, restoring the function of the disrupted lymphatics to normal.

• Compression garments improve drainage by utilizing the working pressures generated by muscular activity.

• Exercises bring a “muscle pump” by generating muscular contractions, which improve lymph flow and protein absorption. Additionally, the earliest lymphatic capillaries expand and widen in response to changes in tissue pressure, which facilitates the easier entry of interstitial fluid into the lymphatic system.

• Meticulous skin care improves skin integrity and prevents new infections.

Materials used in the intervention

An IPC device model AIROS 6 (AIROS Medical Inc. 2501 Monroe Blvd., Suite 1200, Audubon, United States- 19403), class II short-stretch home-made customized compression garments, ball, towel, chair, cot, pillow, and wall

Intervention procedures

The subjects removed clothing and jewelry from the treatment area before treatment, and the therapist did a skin inspection to rule out infections or wounds.

MLD: Subjects sat in a comfortable position and performed abdominal breathing. Using three fingers, the therapist gently stretched the skin over the lymph nodes above the clavicle on both sides. Using the flat surface of the fingers, the therapist gave a gentle pressure over both armpits in a circular motion to pump the lymph nodes. The therapist massaged using the flat surface of the hand in a circular motion: the anterior chest, the involved armpit to (across) the uninvolved armpit, the front, back, and outside of the upper arm (moved up from the elbow to the shoulder); the anterior and posterior aspects of the elbow; the forearm (from the wrist to the elbow). The therapist used their hands to massage all sides of the wrist in a half-circular motion. Rub fingers from knuckle to wrist, palms from center to edge, and nail buds to palm. Followed by abdominal breathing.

IPC: Subjects were asked to wear their own stockinette. A multichambered garment of the AIROS 6 equipment was applied to the patient’s upper limb ^[.

Compression garments: Subjects were asked to wear Class II short-stretch home-made customized compression garments during the day.

Exercises: Subjects engaged in hand ball squeezes, wrist and elbow movements, shoulder shrugging, wand exercise, wall climbing, towel exercise, shoulder bracing, butterfly stretch, overhead clasped hands stretch, shoulder rotations (both clockwise and anticlockwise), and upper body pushups.

Skin care: The therapist educated subjects about meticulous skin care, which includes skin inspection, skin hygiene, and the prevention of skin injury. They had to check the skin every day for redness, scratches, abrasions, or wounds. Daily skin care routines should focus on gently cleansing the skin with a mild cleanser free of soap (as soaps can change the skin’s natural pH and remove the protective sebum layer), patting dry the skin with a gentle motion, and moisturizing the skin with an emollient to replenish lost sebum and retain moisture. They were asked to follow these measures to prevent skin injury: application of sunscreen, usage of insect repellent to prevent bites, usage of electric razors in preference to blades, wearing gloves during gardening, avoiding injections and blood samples on the affected side, avoiding hot pack application, avoiding tight-fitting clothes, watch bands, bracelets, rings, and bra straps.

Provider

The therapist had provided all the procedures to the subjects.

Mode of intervention delivery

The program includes individual therapy sessions and a home-based exercise program.

Setting of the intervention

Assessments and interventions were conducted at the Department of Oncology, PSG Hospitals.

Dosage

The therapist provided all interventions to the subjects for four weeks (five days per week).

MLD: 30 min (five days per week).

IPC: The Lymphoedema Framework recommends using IPC compression levels between 30 and 60 mmHg, adjusting them based on therapy response, and using them as tolerated. Pneumatic compression pressure for UL treatment should be 40 mm Hg, 50 mm Hg, or 30 mm Hg; these values correlate to the 30–60 mm Hg recommended by ISL. Similar to that, throughout four weeks, five days a week, a pressure of 40 to 60 mmHg was applied for 30 min at a time.

Compression garments: pressure of 25–35 mmHg during the day (everyday).

Exercises: During therapy sessions, subjects performed one set of exercises, 15 repetitions each, along with a compression garment. At home, they did four sets of exercises, 15 repetitions each wearing a compression garment.

Tailoring

Subjects experiencing fatigue during exercise took rest intervals between the exercise programs.

Modifications

Not applicable

Fidelity assessment

All the participants were asked to mark their home exercise routine in their logbook, and it was counterchecked by the therapist when the participants had come for therapy sessions. Adherence to other treatment modalities was directly monitored by the therapist, and exercises were performed under supervision during therapy sessions.