Sato, F., Ishida, T., & Ohuchi, N. (2014). The perioperative educational program for improving upper arm dysfunction in patients with breast cancer: A controlled trial. Tohoku Journal of Experimental Medicine, 232, 115–122. 

DOI Link

Study Purpose

To determine the benefit of an educational program on arm and shoulder function for patients with breast cancer given prior to surgery and axillary lymph node dissection three months postoperatively

Intervention Characteristics/Basic Study Process

The intervention group received a three-month educational program on how to monitor arm function, exercises, and how to prevent shoulder dysfunction and lymphedema. Patients were taught how to assess their shoulder function and then were taught how to exercise the arm to improve range of motion postoperatively and reduce the risk of lymphedema. Upper extremity dysfunction included swelling, pain, numbness, weakness, and loss of range of motion on the affected side. The control group received routine care.                                                                                                                                                                                                    

Sample Characteristics

  • N = 149  
  • AGE ≥ 20 years
  • FEMALES: 100%
  • OTHER KEY SAMPLE CHARACTERISTICS: Patients with breast cancer were divided into two groups, those receiving axillary lymph node dissections (ALNDs) and those receiving sentinel lymph node dissections (SLNDs). Within these two groups, patients selected to be either in the intervention or the control group. Exclusion criteria included bilateral breast cancer or recurrence.

Setting

  • SITE: Single site    
  • SETTING TYPE: Other    
  • LOCATION: Miyagi, Japan

Phase of Care and Clinical Applications

  • PHASE OF CARE: Multiple phases of care
  • APPLICATIONS: Assessment of postoperative arm function

Study Design

This was a longitudinal controlled trial that was not randomized. There was a control group and an intervention group.

Measurement Instruments/Methods

  • All measurements were taken at hospital admission, one week postoperatively when the drains were removed, one month postoperatively, and at the close of the study three months postoperatively. 
  • Arm girth measurements included two points, forearm girth and upper arm girth, and comparison to the unaffected side.
  • For grip strength, a standard dynamometer was used, and differences between dominant and nondominant were determined.
  • Shoulder range of motion included three planes, flexion, abduction, and horizontal extension. Differences were calculated.
  • Subjective Perception of Post-Operative Functional Impairment of the Arm (SPOFIA) given preoperatively
  • Disabilities of the Arm, Shoulder, and Hand (DASH)

Results

Of the 149 patients in the study, 69 received ALND and 80 received SLNB. Thirty-nine of the patients from the ALND group and 51 patients from the SLNB group participated in the intervention, and the remaining 30 ALND patients and 29 SLNB patients participated in the control group. Participants were similar in demographic and disease background. In the SLNB group, there were no significant differences in any outcomes between the study intervention and control groups. In the ALND group, there was a significant increase in grip strength through three months postoperatively in the intervention group compared to the control group (p = 0.04). There was a significant improvement in the study intervention group's SPOFIA scores compared to the control group over time (p = 0.02). 

Conclusions

Patients with training prior to breast cancer surgery and ALND developed grip strength and perceived improved arm function compared to those who did not receive training and education. No lymphedema was assessed after two months postoperatively. The exercises and the type of intervention were not described. The outcomes of the program require additional randomized studies.

Limitations

  • Risk of bias (no blinding)
  • Risk of bias (no random assignment)

 

Nursing Implications

Patients with breast cancer usually fail to discuss many symptoms in the DASH or SPOFIA assessment tools. If patients are taught to report these symptoms and not to consider them normal or anticipated, particularly right after surgery, nurses might refer rehabilitation earlier.