Clinical Trial/Experimental Study Medicine ®

Effects of preoperative personal education on

shoulder function and lymphedema in patients
with breast cancer
A consort
Hayoung Byun, MDa, Yunjeong Jang, MDb, Ju-Yeon Kim, MDc, Jae-Myung Kim, MDc, Chang Han Lee, MDa,d,*

Abstract
Background: To compare the incidence and severity of ipsilateral shoulder dysfunction and lymphedema of 2 groups of
patients needing to undergo unilateral breast cancer surgery, one of which had only received printed education materials and the
other group which had received educational materials plus preoperative education.
Methods: We selected 61 patients who had been diagnosed with unilateral breast cancer and planned to undergo surgery.
Before surgery, patients were randomly assigned, either to a control group that only received printed education materials about
exercise for shoulder pain relief and lymphatic edema prevention following breast cancer surgery, or to an experimental group that
received the printed education material with personal education. Participants were evaluated at 1, 3, 6, and 12 months after the
surgery. To evaluate the impairment of shoulder function, we measured the passive shoulder range of motion (ROM), the degree
of pain as visual analog scale (VAS), the short version of the disability of arm, shoulder, and hand (short DASH) scores, and the
shoulder pain and disability index (SPADI). We checked arm circumferences to evaluate lymphedema.
Results: There was no significant difference in demographic or clinical variables between the control and experimental groups.
The experimental group showed significantly less limitation in abduction (P = .042) and forward flexion (P = .039) in the 6 months
following surgery. Change in the VAS, short DASH, and SPADI scores were 1.633 (P < .001), 2.167 (P < .001), and 4.1 (P = .003)
at 1 month following surgery, respectively. These then decreased with time. These changes started before shoulder ROM and arm
circumference changes had occurred, which had started 3 months following surgery.
Conclusions: Preoperative education might be helpful for the prevention of a shoulder ROM limitation, and we need to focus
on pain and disability in patients immediately following breast cancer surgery, and then on ROM and lymphedema.
Abbreviations: DASH = disability of arm, shoulder, and hand, OR = odds ratios, ROM = range of motion, SPADI = shoulder
pain and disability index, VAS = visual analog scale.
Keywords: breast cancer, lymphedema, shoulder function, shoulder motion, shoulder pain

1. Introduction These not only causes cosmetic problems, but they also affect
psychosocial adjustment, quality of life, and functional status.[3,4]
Female breast cancer forms 10% of new cancer diagnosed annu- In particular, surgical trauma and radiation therapy increase the
ally. It is also the leading cause of cancer deaths worldwide for incidence of complications by inducing damage to the axillary
women.[1] Increased levels of obesity, westernized eating habits, lymphatic system.[5] Shoulder dysfunction is one of the common
and reduced breastfeeding have major impacts on the high inci- complications following breast cancer surgery. After axillary
dence of breast cancer among all female cancers.[2] lymph node dissection, 73% of women showed limitation of
Shoulder dysfunction and lymphedema are some of known shoulder movement, tension, edema, pain, loss of arm sensation,
chronic complications that occurs after breast cancer surgery. and limitations of daily life. These complications are caused by

The authors have no funding and conflicts of interest to disclose. University College of Medicine, 79 Gangnam-ro, Jinju, 52727, Republic of Korea
The datasets generated during and/or analyzed during the current study are (e-mail: ychkhk1407@gmail.com).
available from the corresponding author on reasonable request. Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.
Supplemental Digital Content is available for this article. This is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is
a
Department of Rehabilitation Medicine, Gyeongsang National University College
permissible to download, share, remix, transform, and buildup the work provided
of Medicine and Gyeongsang National University Hospital, Jinju, Republic of
it is properly cited. The work cannot be used commercially without permission
Korea, b Department of Rehabilitation Medicine, Gyeongsang National University
from the journal.
College of Medicine and Gyeongsang National University Changwon Hospital,
Changwon, Republic of Korea, c Department of Surgery, Gyeongsang National How to cite this article: Byun H, Jang Y, Kim J-Y, Kim J-M, Lee CH. Effects
University College of Medicine and Gyeongsang National University Hospital, of preoperative personal education on shoulder function and lymphedema in
Jinju, Republic of Korea, d Institute of Health Science, Gyeongsang National patients with breast cancer: A consort. Medicine 2022;101:38(e30810).
University College of Medicine, Jinju, Republic of Korea.
Received: 31 May 2021 / Received in final form: 28 August 2022 / Accepted:
*Correspondence: Chang Han Lee, Department of Rehabilitation Medicine, 30 August 2022
Gyeongsang National University College of Medicine and Gyeongsang National
University Hospital and Institute of Health Science, Gyeongsang National http://dx.doi.org/10.1097/MD.0000000000030810

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Byun et al. • Medicine (2022) 101:38Medicine

tissue and nerve damage. They usually resolve within 3 months, of Helsinki. Approval was granted by the Institutional Review
but some also can become chronic.[6,7] In a study of 141 early Board of Gyeongsang National University Hospital. The trial
breast cancer patients, shoulder function was examined at 18 has been registered prospectively with the Clinical Research
months after the treatment.[8] About half of patients in their Information Service (KCT0002841). It was conducted from
study complained of shoulder dysfunction, and 48% had lim- May 2018 to February 2020.
itation of shoulder joint range of movements (ROM). The fre-
quency of lymphedema is generally about 30%, but the reported
rate varies from 2% to 83%.[9] Lymphedema can occur imme- 2.2. Participants
diately upon or several years following breast cancer treatment. Participants were recruited over a 22-month period. Sixty-one
However, most cases occur within the first 18 months.[9] This patients with unilateral breast cancer who had been sched-
edema is different from the postoperative edema that may occur uled to undergo surgery at our institution from May 2018 to
immediately following surgery. Lymphedema can cause discom- February 2020 were enrolled. The inclusion criteria were as
fort and disability, which may lead to soft tissue infections and follows: subjects aged between 30 and 60 years; diagnosis of
lymphadenitis, and to systemic and sometimes life-threatening unilateral breast cancer; undergo surgery at our institution.
infections.[10] Subjects were excluded under one of the following conditions:
Several studies have reduced shoulder dysfunction and lymph- previous medical history of breast cancer; terminal state; unilat-
edema by physiotherapy, rehabilitation and education.[4,6,11] eral or bilateral upper extremity disease with pain or limitation
Lacomba et al[4] investigated the effects of early physiotherapy of shoulder motion or edema due to other reasons; secondary
following breast cancer surgery to prevent lymphedema, and arthritis of the shoulder due to surgery including shoulder joint,
they found that postoperative physiotherapy was effective at major trauma, or hemiparesis; systemic disease associated with
least 1 year following surgery. In a randomized controlled trial the development of shoulder disease such as diabetes or thyroid
by Beurskens et al,[6] rehabilitation after axillary lymph node dis- disease; poor cooperation due to problems such as cognition.
section for breast cancer treatment reduced shoulder pain and
improved shoulder function and quality of life. There was also a
prospective surveillance model consisting of preoperative eval- 2.3. Intervention
uation and education, initial reevaluation after exercise, exer-
cise program, and continuous surveillance for the prevention Subjects were informed about the clinical trial and consent was
and treatment of shoulder dysfunction and lymphatic edema obtained. Randomization was conducted through block ran-
following breast cancer surgery.[11] Rehabilitation reduced the domization. Prior to the clinical trial, sequences in permuted
incidence of breast cancer-related complications, for both short- blocks with equal numbers of “control” and “intervention”
term and long-term morbidity by enabling early detection and assignments were obtained using a “shuffling envelope” pro-
treatment of disability.[11] cedure. A code manager not involved in the study carried out
There are additional evidences of improvement in shoulder this procedure. At an outpatient visit, before starting educa-
disorders and lymphedema, especially in improved outcomes tion, a physiotherapist not involved in the study obtained the
from early intervention with prospective surveillance models.[11] sequentially numbered, opaque, sealed envelope containing
Therefore, the importance of pre-operative education emerged patient’s assigned intervention and informed the patient of the
as a theory of self-regulation. According to this theory, individ- group assignment. After confirming the group assignment, edu-
uals tend to cope with an illness based on an understanding cation brochures and personal education were provided. The
of their experience.[12] When individuals are informed about educational brochures provided information about prevention
improving their ability to cope with healthcare events, it can of lymphatic edema (Supplemental Digital Content 1, http://
be useful in clinical practice.[12] This implies that patients them- links.lww.com/MD/H418) and exercise of shoulder pain relief
selves need adequate information to understand complications (Supplemental Digital Content 2, http://links.lww.com/MD/
such as shoulder pain and lymphedema following breast can- H419). In the control group, the printed education brochures
cer surgery.[11] If a healthcare professional, such as a primary were provided to read and understand for an hour. In the exper-
care physician fails to educate their patients about the risks of imental group, the printed education brochures were provided,
lymphedema or ways to reduce lymphedema, the patient’s lack and then direct 1:1 education was conducted for 30 minutes
of information about this disease eventually makes them feel dis- about the contents included in the education brochures. After
satisfied with the healthcare professional. This is also unsatisfac- thirty minutes, the researcher confirmed level of understanding
tory for proper management of complications following breast by asking some information verbally and to perform exercise
cancer surgery.[12,13] In contrast, a study by Sugden et al[8] found physically, then taught back some parts that were not fully
that exercise advice following early breast cancer treatment had understood, for 30 minutes. After that, no additional educa-
no impact on shoulder movement limitation. Therefore, effects tion was conducted for the experimental group. The researcher
of information about exercise need to be clarified. informed subjects of both groups to be familiar with the educa-
So far, previous studies were retrospective or prospective tion brochures after breast cancer surgery.
observational studies, and there was not a randomized control
study for preoperative education. The purpose of this study is to
2.4. Outcome measurements
compare the incidence and severity of ipsilateral shoulder dys-
function and lymphedema in 2 groups of patients needing unilat- The primary outcomes of this study were passive shoulder
eral breast cancer surgery, 1 of which had only received printed ROM, the degree of pain as visual analogue scale (VAS), short
education brochures, and the other of which had received both version of the Disability of Arm Shoulder and Hand (short
education brochures as well as personal education. DASH) scores, Shoulder Pain and Disability Index (SPADI), and
arm circumferences. The secondary outcomes were odds ratios
(OR) for shoulder ROM limitation, and timing of change in
2. Methods shoulder motion, pain, dysfunction and arm circumferences.
The baseline evaluation at zero week (before surgery) was
2.1. Study design performed including demographic variables (age, height, body
This is a prospective randomized controlled study with blinded weight, body mass index, dominant hand, previous medical his-
assessor and patient (to outcome), conducted in the Department tory, occupational state, and education level) and clinical vari-
of Rehabilitation Medicine at a university hospital. This study ables (location of the breast cancer, cancer stage, surgery type,
was performed in line with the principles of the Declaration results of lymphangiography, presence of lymph node dissection,
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and duration of postoperative drain). Evaluation of ipsilateral significant difference in abduction and forward flexion between
shoulder function and lymphedema were performed at 1, 3, 6, control and experimental groups at 6 months after the surgery
and 12 months following surgery. To evaluate the impairment of (Table 2). Shoulder abduction of control group was 176.0 ± 7.24,
shoulder function, passive shoulder ROM, the degree of pain as while experimental group was 179.0 ± 3.01, at 6 months after
VAS, short DASH scores, and SPADI were measured. the surgery. Also, shoulder forward flexion of control group was
The ROM (abduction, forward flexion, and external rota- 175.7 ± 7.74, while experimental group was 179.0 ± 3.01, at
tion) of the subject’s shoulder joint was measured using a goni- 6 months after the surgery. Therefore, the experimental group
ometer with limited scapular movement by a medical doctor. In showed significantly low limitation in abduction (P = .042) and
addition, the Apley scratch test was used to evaluate internal forward flexion (P = .039) of the shoulder joint than control
rotation.[14] VAS was used to represent the degree of pain, with group (Table 2).
zero being no pain to 10 being to the most severe pain imagin- The OR for abduction being below 180 was 1.930, with the
able.[15] The short DASH was used instead of the 30-item DASH, 95% CI 0.088 to 3.772 (P = .043) at 1 month after surgery.
which was as reliable and sensitive as 30-item DASH.[16] The It was 1.950 with the 95% CI 0.090 to 3.672 (P = .044) at 6
SPADI is a self-administered questionnaire that can be used to months after surgery. The OR for forward flexion being below
assess shoulder pain and functional limitations.[17] 180 degrees was also 1.983 with the 95% CI 0.111 to 3.885
To evaluate lymphedema, the arm circumferences were mea- (P = .038) at 1 month after surgery, and it was 1.902 with the
sured with a tape measure. Both arms were placed on the table 95% CI 0.101 to 3.894 (P = .039) at 6 months after surgery.
with the shoulder joints in a neutral state and bent 45 degrees, Therefore, OR for abduction and forward flexion being below
while the forearm was maintained in maximum supination. 180 degrees were significantly higher than being 180 degrees at
The circumferences of the arm at a distal and proximal dis- 1 and 6 months after the surgery. In addition, OR for exter-
tance of 5 cm from the elbow fold were measured as reference nal rotation being below 90 degrees was 2.304 with the 95%
points. The circumferences differences of 2 cm or more were CI 0.552 to 4.057 (P = .010), 2.923 with the 95% CI 1.130
regarded as being significant edema.[18] This method is known to 4.717 (P = .001), 3.223 with the 95% CI 1.411 to 5.035
to be valid and reliable for the accurate diagnosis and measure- (P = .001) and 1.600 with the 95% CI 0.603 to 4.248 (P = .001)
ment of secondary lymphedema.[19] The sample size was calcu- at 1, 3, 6, and 12 months after the surgery, respectively (Table 3).
lated with Epidat Software (Health Situation Analysis Program, Although OR for shoulder ROM limitation was not statisti-
Washington D.C.), using the VAS as the primary outcome mea- cally different between control and experimental groups, it was
surements of shoulder pain. Based on similar studies (numeric always higher in control groups at all follow-ups following sur-
rating pain scale difference in means of 2.17 points; standard gery, except for OR in the 1 month for the external rotation
deviation: 1.6) with 80% power and an alpha level of 0.05, a (similar tendency) (Fig. 2).
total sample size of 30 patients in each arm was estimated to Changes in shoulder internal rotation, pain VAS, short DASH,
enter this study design.[20,21] SPADI score, and arm circumferences were not significantly dif-
ferent between 2 groups at any time (not shown).
Because there were no significant differences between 2
2.5. Statistical analysis groups at any time, the average changes in shoulder motion,
Demographics and clinical variables were compared through pain, dysfunction, and arm circumferences in all patients were
Wilcoxon rank-sum test, Fisher’s exact test and Chi-square test, analyzed. Internal rotation evaluated by Apley scratch test sig-
according to the characteristics of variables. Changes of shoul- nificantly increased 0.75 cm (P = .023), and 0.72 cm (P = .020),
der movement, pain, shoulder function and arm circumferences at 3 and 6 months following surgery (Table 4). The pain VAS sig-
were compared using Mann–Whitney U test. Odd ratios for nificantly increased 1.633 scores (P < .001) 1 month following
shoulder ROM limitation was analyzed using generalized linear surgery, then significantly decreased 0.833 scores (P = .006) and
mixed model with binomial distribution, and average changes 0.600 scores (P = .046), at 3 and 6 months after surgery. The
in shoulder motion, pain, dysfunction and arm circumferences short DASH significantly increased 2.167 scores (P < .001) 1
were analyzed using generalized linear mixed model with nor- month following surgery, and then significantly decreased 1.267
mal distribution. scores (P = .015) 3 months following surgery. The SPADI signifi-
All tests were 2-tailed and a P value of < .05 was considered cantly increased 4.100 scores (P = .003) 1 month following sur-
statistically significant. All statistical analyses were performed gery, which then significantly decreased 1.075 scores (P = .036)
using SAS Ver. 9.4 (SAS Institute, Cary). at 12 months following surgery. Arm circumference 5 cm above
elbow significantly increased 0.480cm (P = .014) and 0.450 cm
(P = .021) at 3 and 6 months following surgery. The arm circum-
3. Results ference 5 cm below elbow also significantly increased 0.493 cm
(P = .013) at 6 months following surgery (Table 4).
Seventy-nine patients with unilateral breast cancer were screened
for the trial, 62 of whom were eligible. Of these patients, thir-
ty-one were assigned to the experimental group, and thirty-one
were assigned to control group. One patient in the control 4. Discussion
group dropped out during the follow-up because of a medical In the present study, shoulder dysfunction and lymphedema fol-
problem and its treatment. Figure 1 shows the flow of partici- lowing unilateral breast cancer surgery were assessed, and dif-
pant enrollment in the study. Finally, 61 patients were evaluated, ferences between groups according to preoperative education
and 31 were experimental (50.8%) and 30 were control group were compared. Among the 61 subjects with unilateral breast
(49.2%). There were no differences in either the demographic cancer surgery, patients who received pre-operative personal
and clinical variables between both groups, including age, education showed less limitation in shoulder abduction and for-
height, body weight, body mass index, dominant hand, previous ward flexion at 6 months, compared to those patients who did
medical history, occupational state, education level, location of not receive preoperative personal education. Therefore, preop-
the breast cancer, cancer stage, surgery type, results of lymphan- erative personal education is helpful for prevention of shoulder
giography, presence of lymph node dissection, and duration of ROM limitation. The OR for shoulder ROM limitation was also
postoperative drain (Table 1). higher in subjects supplied with printed education brochures
There was no significant difference between 2 groups in only as compared to subjects with preoperative personal educa-
external rotation, internal rotation, pain VAS, short DASH tion, although this was not of statistical significance. Therefore,
score, SPADI score and arm circumference except there was a the results of the present study support the hypothesis that

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Figure 1. Flow diagram for study participants.

preoperative personal education about shoulder motion and well-being and satisfaction.[26–29] According to the systematic
function effectively helps to reduce postoperative complications review by Moyer et al,[30] preoperative education and/or exer-
in patients with breast cancer. On the last follow up day of the cise improved function, quadriceps strength, and length of stay
present study, patient’s satisfaction about the preoperative edu- in patients undergoing total knee arthroplasty, and it improved
cation was investigated. In the survey questioning the level of pain, function, and length of stay in patients undergoing total
understanding, quality, location, timing and type of education, hip arthroplasty.
96.7% of patients reported over 80% satisfaction. The result Timing of the education has been studied with diversified
indicates additional support for the role of preoperative educa- conditions. Preoperative education helps to conduct both preop-
tion in patients with breast cancer surgery. erative and postoperative exercise by letting patients to exercise
Breast and axillary surgery with radiotherapy are parts of the by themselves before they enter a period of potential immobility
standard treatment for breast cancer, which can cause scar and or decreased activity. The present results are in agreement with
wound formation, fibrosis, shortening of soft tissues and sec- the results of a previous study carried out by Imamoğlu et al,[31]
ondary muscle activity loss. Although less extensive surgery and who reported significantly better shoulder functions in patients
possible reduction of radiotherapy have been tried, subsequent who had been educated about lymphedema. In their study, 1
limitation in shoulder ROM with pain and disability are still group was educated about causes and symptoms of lymph-
observed.[22] To prevent such complications, preoperative and edema, as well as strategies for lymphedema care such as skin
postoperative exercises have been studied concerning its role care, exercises, and changes to be made in daily life activities,
and timing. while the other group was not educated. Although subjects were
Previous studies about the role of education in other chronic patients with lymphedema, shoulder function improved with
diseases such as diabetes, hypertension and ankylosing spon- education. However, their study was about education after the
dylitis elucidated its positive effects.[23–25] Additional studies occurrence of lymphedema, which is different from the pres-
showed that preoperative education reduced fear, anxiety, pain ent study dealing with education before the surgery. There was
and the length of hospital stay, and it increased psychological a prospective study dealing with a perioperative educational

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Table 1
Demographic and clinical variables.
Characteristics Control group (n = 30) Experimental group (n = 31) P value

Age (yrs) 56.16 ± 11.05 55.60 ± 12.41 .530†

Height (cm) 157.4 ± 6.13 156.8 ± 5.05 .891†
Body weight (kg) 60.46 ± 13.50 61.59 ± 10.38 .530†
Body mass index (kg/m2) 24.29 ± 4.35 25.05 ± 3.73 .286†
Dominant hand 1.000‡
 Right (n) 29 30
Left (n) 1 0
 Both (n) 0 1
Previous medical history .510§
 Absent (n) 12 15
Present (n) 18 16
Occupational state .717§
Unemployed (n) 19 21
Employed (n) 11 10
Education yr (yrs) 10.73 ± 3.60 11.58 ± 4.00 .188†
Location of breast cancer .083‡
 Right (n) 14 16
Left (n) 16 15
Cancer stage .435‡
DCIS (n) 3 3
Invasive carcinoma grade I (n) 11 13
Invasive carcinoma grade II (n) 11 12
Invasive carcinoma grade III (n) 4 3
Invasive carcinoma grade IV (n) 1 0
Surgery type .231‡
BCS (n) 24 21
MRM (n) 4 5
Total mastectomy (n) 0 1
Nipple sparing mastectomy (n) 2 3
Wide excision (n) 0 1
Lymphangiography result .370‡
Not checked (n) 19 21
Secondary lymphedema (n) 2 1
LNs uptake (n) 8 7
No visualized LNs (n) 1 1
No focal uptake (n) 0 1
Presence of lymph node dissection .097§
SLNB alone (n) 15 18
Partial ALND (level I~II) (n) 15 13
Duration of postoperative drain (d) 6.97 ± 2.08 6.32 ± 2.87 .213†
ALND = axillary lymph node dissection, BCS = breast conserving surgery, DCIS = ductal carcinoma in situ, LN = lymph nodes, MRM = modified radical mastectomy, SLNB = sentinel lymph node biopsy.
†P value by Wilcoxon rank-sum test.
‡P value by Fisher’s exact test.
§P value by Chi-square test.

program.[32] That study included 37 patients in perioperative Types of the education also needs to be considered. There was
educational program, and 27 patients in control group supplied a study comparing in-person instruction with video teaching for
written information about shoulder exercise. The perioperative shoulder prehabilitation exercise for patients with breast can-
educational program given before surgery resulted in improved cer.[34] In their study, in-person teaching was not significantly
horizontal extension and an improved Subjective Perception of superior to video teaching. However, their study was different
Post-Operative Functional Impairment of the Arm scores. The with the present study comparing education brochures supply
result was similar to the present study, but it was a nonrandom- with preoperative personal education, which showed significant
ized, controlled trial. Education not only affects shoulder func- advantage in shoulder ROM limitation. The difference might be
tion, but also lymphedema. Fu et al[33] analyzed patients with due to the time cost for video teaching, which would be longer
breast cancer-related lymphedema and concluded that patients than reading the educative brochures in the present study. Time
who had received information about lymphedema had signifi- consuming would include time for explanation and confirma-
cantly fewer symptoms of it. The present study did not show tion of understanding about the explained information.
significant differences in arm circumferences between 2 groups. Lokapavani et al[35] reported that patients with prehabilita-
The difference in results might be because of the contents of tion of the glenohumeral and scapulothoracic joint ROM exer-
information provided before the surgery. In the study by Fu cises were more resistant to shoulder ROM limitation, disability,
et al,[33] they concluded that information about breast cancer and pain. Postoperative shoulder ROM exercise also showed a
related lymphedema had helped patients to stay away from the moderate level of evidence of improved shoulder flexion, abduc-
avoidable risk factors that can lead to lymphedema. The present tion, and external rotation, whereas muscle strengthening exer-
study contained more information about exercise than about cise exhibited less evidence for improved shoulder function.[36]
risk factor avoidance. Therefore, preoperative education that Therefore, shoulder ROM and strengthening exercise before
contains information directly related to lymphedema prevention and after the surgery would help to prevent shoulder dysfunc-
would be helpful in improving arm swelling and lymphedema. tion and restore its function. Limitation in shoulder movement,

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Table 2
Changes of shoulder movement, pain, shoulder function and arm circumferences.
Measure Evaluation time Control group (n = 30) Experimental group (n = 31) P value

Shoulder passive
ROM (degrees)
Abduction
 Before surgery 175.7 ± 15.47 178.4 ± 4.54 .902
 1 mo after surgery 174.7 ± 11.06 177.7 ± 4.97 .291
 3 mo after surgery 176.0 ± 8.94 178.1 ± 4.77 .429
6 mo after surgery 176.0 ± 7.24 179.0 ± 3.01 .042*
12 mo after surgery 176.8 ± 14.80 178.6 ± 3.55 .210
Forward flexion
 Before surgery 175.8 ± 15.87 178.7 ± 3.41 .883
 1 mo after surgery 173.7 ± 14.50 178.4 ± 3.74 .156
 3 mo after surgery 175.3 ± 11.06 178.4 ± 3.74 .393
6 mo after surgery 175.7 ± 7.74 179.0 ± 3.01 .039*
12 mo after surgery 176.5 ± 6.61 179.6 ± 3.55 .194
External rotation
 Before surgery 85.33 ± 12.79 86.45 ± 8.77 .880
 1 mo after surgery 81.00 ± 13.48 83.55 ± 10.18 .628
 3 mo after surgery 81.50 ± 12.26 84.19 ± 8.86 .448
6 mo after surgery 80.67 ± 13.63 83.23 ± 9.09 .629
12 mo after surgery 80.00 ± 15.06 84.14 ± 8.27 .356
Internal rotation
 Before surgery 7.73 ± 9.04 7.16 ± 8.40 .885
 1 mo after surgery 8.46 ± 8.85 7.92 ± 9.00 .659
 3 mo after surgery 8.48 ± 8.82 7.47 ± 8.30 .603
6 mo after surgery 8.48 ± 8.72 7.45 ± 8.51 .598
12 mo after surgery 8.42 ± 9.08 7.72 ± 8.78 .399
Pain VAS
 Before surgery 0.30 ± 1.47 0.13 ± 0.50 .973
 1 mo after surgery 1.93 ± 2.39 1.55 ± 2.06 .502
 3 mo after surgery 1.13 ± 1.38 1.13 ± 1.50 .872
6 mo after surgery 0.90 ± 1.30 0.61 ± 0.92 .500
12 mo after surgery 0.42 ± 0.81 0.51 ± 1.01 .698
Short DASH score
 Before surgery 2.23 ± 11.50 0.52 ± 1.69 .451
 1 mo after surgery 3.00 ± 3.69 2.35 ± 2.96 .600
 3 mo after surgery 2.10 ± 2.72 1.39 ± 1.86 .509
6 mo after surgery 1.70 ± 2.38 0.77 ± 1.18 .170
12 mo after surgery 0.97 ± 1.64 0.57 ± 1.01 .524
SPADI score
 Before surgery 0.83 ± 4.04 0.32 ± 1.14 .693
 1 mo after surgery 6.33 ± 8.52 7.42 ± 10.54 .660
 3 mo after surgery 4.53 ± 5.83 3.29 ± 3.93 .813
6 mo after surgery 3.07 ± 4.60 1.35 ± 1.99 .267
12 mo after surgery 1.19 ± 2.09 1.08 ± 2.02 .883
Arm circumferences (above elbow 5cm) (cm)
 Before surgery 24.59 ± 2.53 24.81 ± 2.42 .707
 1 mo after surgery 24.86 ± 2.60 24.79 ± 2.59 .983
 3 mo after surgery 25.07 ± 2.88 24.91 ± 2.39 .908
6 mo after surgery 25.04 ± 2.77 25.00 ± 2.67 .948
12 mo after surgery 24.78 ± 2.55 25.07 ± 2.60 .541
Arm circumferences (below elbow 5 cm) (cm)
 Before surgery 23.04 ± 2.09 23.09 ± 2.00 .520
 1 mo after surgery 23.14 ± 2.11 23.35 ± 2.02 .588
 3 mo after surgery 23.27 ± 2.45 23.33 ± 2.08 .767
6 mo after surgery 23.53 ± 2.44 23.39 ± 1.88 .994
12 moafter surgery 23.18 ± 2.45 23.68 ± 2.20 .287
C = control group, DASH = disability of arm shoulder and hand outcome measure, E = experimental group, ROM = range of movement, SPADI = shoulder pain and disability index, VAS = visual analogue
scale.
*P < .05, P value by Mann–Whitney U test.

especially forward flexion and abduction, improved by the pre- preoperative level following a Physiotherapy Management Care
operative personal education in the present study. Although it Plan. Although there are other studies showing shoulder ROM
was 3.0 to 3.3 degrees, the difference was significant. This is improvement in external rotation or internal rotation, more
similar with previous randomized controlled trial showing a studies would be required to reveal the exact effect of breast
greater improvement in shoulder flexion and abduction in post- cancer surgery and preoperative shoulder exercise on shoulder
surgical breast cancer subjects who had training in excise pro- mobilization.[39,40] According to the study by Shamley et al,[41]
gram of passive stretching and progressive resistance training.[37] muscle activity of trapezius evaluated by electromyogram was
Also, Box et al,[38] showed a quicker return of abduction to lower on affected side following breast cancer surgery, and the

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Table 3
Odd ratios for shoulder range of motion limitation.
Shoulder ROM Evaluation time OR (95% CI) P value

Abduction < 180

1 mo after surgery 1.930 (0.088-3.772) .043*
3 mo after surgery 1.246 (-0.605-3.097) .192
6 mo after surgery 1.950 (0.090-3.672) .044*
12 mo after surgery 2.076 (0.624-7.253) .093
Forward flexion < 180
1 mo after surgery 1.983 (0.111-3.885) .038*
3 mo after surgery 1.280 (-0.598-3.158) .183
6 mo after surgery 1.902 (0.101-3.894) .039*
12 mo after surgery 2.087 (0.602-7.229) .087
External rotation < 90
1 mo after surgery 2.304 (0.552-4.057) .010*
3 mo after surgery 2.923 (1.130-4.717) .001*
6 mo after surgery 3.223 (1.411-5.035) .001*
12 mo after surgery 1.600 (0.603-4.248) .001*
CI = confidence interval, OR = odds ratio, ROM = range of motion.
*P < .05, P value by Generalized linear mixed model with binomial distribution.

Figure 2. Odd ratios for shoulder range of motion limitation in control and experimental groups. (A)Shoulder abduction being below 180 degrees. (B) Shoulder
forward flexion being below 180 degrees. (C) Shoulder external rotation being below 90 degrees.

muscle size of pectoralis major and minor were significantly as format, content, and timing were not conducted, and these
smaller on the affected side. The pectoralis muscles are also in would help to support more about the importance of education
the surgical field of the breast cancer.[42] Therefore, shoulder in future studies. The ROM difference were less than 5 degrees,
movement related to these muscles would require more atten- which need further evaluation about the role of presented
tion for postoperative care. ROM difference in relation to the shoulder function. Further
Acute postoperative pain, which may arise from surgical prospective studies are required to strengthen these results.
tissue trauma and related acute inflammatory processes, tend This study demonstrates that preoperative personal educa-
to resolve within 2 to 10 days following surgery.[43] Pain may tion is helpful for the prevention of shoulder abduction and for-
last beyond the healing of injured tissue inflammation, and it ward flexion limitation. Pain, short DASH, SPADI significantly
may persist for several months following surgery. Around 10% increased at 1 month following surgery, while shoulder internal
to 50% of patients who undergo surgery develop persistent rotation and arm circumferences significantly increased at 3
post-surgical pain.[44] Following breast cancer surgery, around months following surgery. Therefore, healthcare providers need
40% of patients reported persistent pain until 1 year.[45] The to focus on pain and disability in patients immediately follow-
present study also showed a similar tendency. Pain and disabil- ing breast cancer surgery and then to move on to ROM and
ity tended to increase immediately following surgery, which then lymphedema for better postoperative follow up.
decreased with time. These changes started prior to shoulder
ROM and arm circumference change, which started 3 months
Author contributions
following surgery. Therefore, the present study suggests focusing
on pain and disability for the first month in postsurgical breast Conceptualization: Yunjeong Jang, Chang Han Lee.
cancer patients, then focusing on shoulder ROM and lymph- Data curation: Yunjeong Jang, Ju-Yeon Kim, Jae-Myung Kim.
edema for next 3 months. Formal analysis: Yunjeong Jang, Chang Han Lee.
The main strength of the present study is the randomized Methodology: Yunjeong Jang,Chang Han Lee.
control study design, since it enables direct evaluation of the Investigation: Yunjeong Jang, Ju-Yeon Kim, Jae-Myung Kim.
role of preoperative personal education. In addition, this study
Project administration: Chang Han Lee.
followed up subjects for a year following surgery to compare
and confirm any late complications. However, there are some Software: Hayoung Byun, Chang Han Lee.
limitations. The study was carried out at a single center and the Supervision: Chang Han Lee.
number of patients was insufficient for subgroup analysis, such Validation: Yunjeong Jang, Chang Han Lee.
as surgery type, presence of lymph node dissection, lymphangi- Visualization: Hayoung Byun, Yunjeong Jang.
ography result, and cancer stage. In addition, evaluation about Writing – original draft: Hayoung Byun, Chang Han Lee.
patient’s experience with education and type of education such Writing – review & editing: Hayoung Byun, Chang Han Lee.

7
Byun et al. • Medicine (2022) 101:38Medicine

Table 4
Average changes in shoulder motion, pain, dysfunction, and arm circumferences.
Measure Evaluation time P value

Shoulder ROM Change in cm

Internal rotation
1 mo after surgery 0.821 .103
3 mo after surgery 0.750 .023*
6 mo after surgery 0.720 .020*
12 mo after surgery 0.055 .759
Pain VAS Change in scores
1 mo after surgery 1.633 <.001*
3 mo after surgery -0.833 .006*
6 mo after surgery -0.600 .046*
12 mo after surgery -0.478 .999
Short DASH Change in scores
1 mo after surgery 2.167 <.001*
3 mo after surgery -1.267 .015*
6 mo after surgery -0.867 .094
12 mo after surgery -0.465 .949
SPADI Change in scores
1 mo after surgery 4.100 .003*
3 mo after surgery -2.300 .088
6 mo after surgery -0.833 .536
12 mo after surgery -1.075 .036*
Arm circumference above elbow 5 cm Change in cm
1 mo after surgery 0.270 .167
3 mo after surgery 0.480 .014*
6 mo after surgery 0.450 .021*
12 mo after surgery -0.095 .394
Arm circumference below elbow 5 cm Change in cm
1 mo after surgery 0.103 .599
3 mo after surgery 0.230 .243
6 mo after surgery 0.493 .013*
12 mo after surgery -0.030 .343
DASH = disability of arm shoulder and hand outcome measure, ROM = range of motion, SPADI = shoulder pain and disability index, VAS = visual analogue scale.
*P < .05, P value by Generalized linear mixed model with normal distribution.

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