This study found that patients enrolled in a community-based lymphedema management program experienced less disability in almost every domain of the WHO-DAS II, including participation in community life and cognition, compared to baseline. These benefits were sustained through two years of follow-up. These results are consistent with other studies which have demonstrated decreased disability, fewer ADL episodes, and improved quality of life amongst lymphedema patients involved in lymphedema management programs 
After controlling for other predictors, including time in the program, the best predictor of patient perceived disability was self-reported health status in the previous 30 days. Worsening reported health status corresponded with increases in WHO-DAS II composite disability scores at every time point in the survey, indicating that self-reported health status may serve as a simple proxy measure for composite perceived disability among lymphedema patients.
Other significant contributors to increases in composite disability scores were older age and advanced lymphedema. Though this study found that the oldest patients had the highest disability scores at both baseline and 24 months after enrollment, these patients also experienced the greatest percent declines in these scores over their two years in the program. This same pattern held true for patients with the most advanced lymphedema (Stages 4–7), who experienced greater percent declines in their composite disability scores than patients with less advanced lymphedema (Stage 1–2). These findings suggest that simple, low-cost interventions, such as those used in this community-based lymphedema management program, can significantly impact perceived levels of disability for even the oldest and most advanced lymphedema patients, even in the absence of more intensive and costly interventions such as bandaging, massage, and IV antibiotics.
Younger patients and those with early stage lymphedema and lower levels of disability at enrollment also perceived less disability after participation in the lymphedema management program. The findings suggest that early exposure to lymphedema management may substantially decrease perceived disability among patients in the early stages of lymphedema. As community-based lymphedema management programs expand, an emphasis on prompt enrollment of patients with stage 1 or 2 lymphedema will be particularly important. Increased community awareness of LF and efforts to reduce stigma will likely be vital to the identification and enrollment of early stage lymphedema patients.
After controlling for other predictors, reporting an ADL episode in the previous 30 days remained a significant predictor of increased disability. Prior research has demonstrated that the prevention of ADL episodes slows long-term lymphedema progression 
; our data demonstrate that reducing the number of ADL episodes also decreases patients' perceived level of disability. Our results suggest that lymphedema management techniques that assist in preventing ADL episodes can reduce patient disability as well as increase productivity and participation in society. While this study focuses on perceived disability as a surrogate for quality of life, it is interesting to note that the maximal reduction in perceived disability occurred between 2 and 6 months, a period reported by others as the time of maximum impact on ADLA episodes 
. A more detailed analysis of the effect of this lymphedema management program on ADLA episodes is underway.
These reductions in disability can have significant economic impact for both the patients and their communities. At twenty-four months post-enrollment, patients in our study gained an average of 2.4 work days per month as the result of decreased perceived disability. If extrapolated to all 17,036 (Little KM, unpublished data) lymphedema patients in Khurda District, this translates into approximately 2,688 person-years of productive time gained over the course of the twenty-four month study period. These findings suggest that substantial economic gains for individuals, families, and communities would result from an increased emphasis on LF morbidity reduction, especially in high-prevalence areas. In India, where nearly 20 million individuals suffer from symptomatic LF infections 
, the economic benefits of lymphedema management programs in terms of work days saved would be considerable.
Although lymphedema management improved disability scores over time, advanced lymphedema, the presence of other chronic health conditions, and female gender remained strong predictors of worse perceived disability. Though patients with advanced lymphedema experienced the largest reduction in their perceived disability during the study, their composite disability scores remained higher than young or early stage patients for the entire follow-up period. While community-based lymphedema management programs may provide increased access to hygiene supplies and education, they are typically unable to offer patients with advanced lymphedema more expensive and intensive therapies such as bandaging, antibiotics, and a specialized referral infrastructure. Effective control of LF-related morbidity may require dual development of low-cost community interventions alongside more complex services for patients with advanced lymphedema and other chronic health conditions. Further research should explore the feasibility and effectiveness of these interventions in low-resource settings. Opportunities for collaboration with other chronic health programs including those focusing on diabetes, leprosy, and venous insufficiency, should also be explored. Finally, future work should focus on women's health in relation to lymphedema in an effort to reduce the disability gender-gap observed in this study.
This study had several limitations. First, survey results were based on patient recall and perceived disability during the previous 30 days and may be subject to recall bias. Patients enrolled in this study were included based on the presence of lymphedema in one or both legs. Because blood was not drawn to test for the presence of microfilaremia or filarial antigenemia the lymphedema management program may have enrolled patients with non-filarial lymphedema. Nevertheless, it is important to note that lymphedema management programs are recommended for lymphedema resulting from all causes. Additionally, the study is limited by the lack of a comparable control group not receiving the community-based lymphedema management program, as it is considered inappropriate to withhold knowledge of lymphedema management techniques from patients with lymphedema.
In order to account for repeat measurements over time, we used a mixed effects model that incorporated time as a variable in both the univariate and multivariate analyses. Because compliance with foot care was dramatically increased at all assessments subsequent to baseline, our model likely underestimates the effect of compliance with foot care on overall disability score. Indeed, compliance with foot care becomes highly significant when time is taken out of the model (data not shown). Finally, there was an increase in most WHO DAS II domain scores at 12 months compared to 6 months. It is not unexpected to see fluctuations in perceived disability from chronic diseases; more frequent or longer monitoring would provide a better sense of whether the benefits we have observed will be sustained. Future research will address the relationship between ADL episodes and lymphedema progression in this cohort.
While the effects of lymphedema management on clinical disease, disability, and quality of life have been studied previously 
, this is one of the first evaluations of a community-based lymphedema management program with 24 month longitudinal follow-up. Our findings indicate that community-based lymphedema management programs can reduce patient perceived disability and reduce the number of work days lost due to lymphedema symptoms. Significantly, these effects were maintained for two years following program enrollment. These data emphasize the need for national lymphatic filariasis elimination programs to prioritize morbidity management and disability prevention programs to improve the lives of those suffering from lymphedema associated with lymphatic filariasis.