Assiut Scientific Nursing Journal Ahmed et al.

, 74

Effect of Applying Shoulder Exercises on Shoulder Function after Modified Radical

Mastectomy
Eman M. Ahmed, Mimi M. Mekkawy & Ahmed Awad Sayed.
Assistant lecturer of Medical-Surgical Nursing, Faculty of Nursing, Beni-Sueif University, Egypt.
Professor of Medical-Surgical Nursing, Faculty of Nursing, Assiut University, Egypt.
Assistant Professor of Surgical oncology, South Egypt Cancer Institute, Assiut University, Egypt.

Abstract
Aim of study: was to identify the effect of applying shoulder exercises on shoulder function after modified
radical mastectomy. Research design: Quasi-experimental design was utilized. Setting: data were collected from
the surgical oncology department and surgical outpatient clinic at South Egypt Cancer Institute - Assiut
University. Subjects: The study was conducted on (80) adult female patients with breast cancer scheduled for
modified radical mastectomy and were randomly and alternatively divided equally into study and control groups;
(40) for each. Tools: data were collected using three tools: Tool (I): Structured Interview Questionnaire; including
two parts, tool (II): Shoulder range of motion assessment questionnaire and tool (III): Shoulder functional ability
assessment questionnaire. Results: More than half of women in both groups, their ages ranged between (40 - 60)
years with mean ages (45.5±11.7) for the study group & (44.8±10.8) for the control group. Majority of the study
group had normal shoulder function while most of the control group had difficulty in shoulder function (80% &
60%) respectively one month after exercise. Conclusion: Utilizing post mastectomy shoulder exercises
significantly improves shoulder function and shoulder range of motion for patients undergoing modified radical
mastectomy. Recommendations: Increase level of awareness among patients regarding shoulder exercises.

Keywords: Breast Cancer, Modified Radical Mastectomy, Shoulder Exercises & Range of Motion.

Introduction al., 2016). According to South Egypt Cancer

Breast cancer is usually treated by surgery, which Institute statistical records, the incidence of breast
may be followed by chemotherapy or radiation cancer in 2014 were about 490 patients (483
therapy or both. A multidisciplinary approach is females and 7 males), (Statistical Records of
preferable. Mastectomy is a surgery to remove one South Egypt Cancer Institute, 2014).
or both breasts; there are many types of Many women will have impairment in shoulder
mastectomy, such as simple mastectomy, movement that can significantly affect their daily
subcutaneous mastectomy, skin-sparing function and quality of life. Restriction of shoulder
mastectomy, nipple-sparing mastectomy, radical movement is one of the complications following
mastectomy and modified radical mastectomy modified radical mastectomy and axillary lymph
(Saini, et al., 2011 and Williams & Hopper, node dissection; it may occur as a result of nerve
2011). and tissue lesions. To reduce the impairment of
Modified radical mastectomy is the most common strength and mobility of the shoulder, shoulder
treatment of invasive breast cancer and it is the exercises are commonly prescribed (Bahgat, et al.,
removal of all breast tissue from the affected breast 2016).
with removal of lymph nodes from the armpit in the Early physiotherapy especially shoulder exercise is
affected side of the body. This surgery includes the a common treatment to avoid shoulder dysfunction
removal of both nipples and areola (Shaaban, and restricted shoulder mobility. Physical therapist
2013). Many complications may occur after can suggest and perform post mastectomy exercises
modified radical mastectomy such as restricted that help to regain movement and strength in arm
shoulder mobility, shoulder dysfunction, wound and shoulder, reduce stiffness and improve quality
infection, stiffness, seroma formation, pain and of life (Brito, et al., 2012 & Galantino & Stout,
lymphedema (Bahgat, et al., 2016). 2013).
Worldwide, breast cancer is the most common Nurses are the largest group of health professionals
invasive cancer in women. It affects about 12% of who have direct contact with the patients, they play
women around the world (McGuire, et al., 2015). an important role in improving shoulder functions
The American Cancer Society's estimates of breast and restoring the full range of motion of shoulder
cancer in the United States in 2015 for about and arm after modified radical mastectomy by
231,840 new cases of invasive breast cancer and giving certain directions and instructions regarding
about 40,290 women would die from it (American postoperative exercises and protective care
Cancer Society, 2015). measures to prevent shoulder dysfunction (Bahgat,
In a recent epidemiological study in the Egyptian et al., 2016). The nursing management of breast
cancer institute, breast cancer represented 35.1% of cancer patient includes assessing the patient’s
the total female cancer cases in Egypt (Faisal, et needs, making appropriate nursing diagnosis and

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Assiut Scientific Nursing Journal Ahmed et al., 75

initiate plans for care, helping her to cope with were divided into two equal groups; (40) for each,
emotions, providing information and psychological the study group performed postmastectomy
support (Sullivan & Mansour, 2015 & Darweesh, shoulder exercises and the control group received
et al., 2016). routine care. To ensure the randomization, the odd
numbers were given to the group that performed
The Aim of the studys post mastectomy shoulder exercises while the even
To identify the effect of applying shoulder numbers were given to the group that received
exercises on shoulder function after modified routine care. They were selected according to the
radical mastectomy. following criteria: conscious, in the preoperative
Research hypotheses period and accepted to participate in the study.
The following research hypotheses were formulated Exclusion criteria included
to fulfill the aim of the study Patients with severe deformity, any trauma or
 Shoulder function in females in the study group diseases affecting muscles and joints such as
will improve than that in females in the control rheumatoid arthritis, skin grafting on or around the
group. shoulder, previous history of chronic illness such as
 Shoulder range of motion in females in the study diabetes, osteoporosis, renal failure, heart disease,
group will improve than that in females in the pulmonary diseases, neurological dysfunction and
control group. patients undergoing neck surgery were excluded
from the study subjects.
Significance of the study Tools of data collection
The researcher observed that there is an increase in Three tools were used for data collection;
the incidence of breast cancer in South Egypt Tool (I): Structured Interview Questionnaire
Cancer Institute at Assiut University, about 490 It was developed by the researcher after extensive
patients (2014) and modified radical mastectomy is review of the relevant literature and it was used to
a common surgical procedure in breast cancer. obtain baseline data of the patients, it consisted of
After surgery, the most common postoperative two parts:
complications are shoulder dysfunction and Part I: Socio-demographic data: such as the
restricted shoulder mobility. To reduce or prevent patient's name, age, marital status, level of
these complications, shoulder exercises are usually education, occupation and residence area.
prescribed. Part II: Clinical data: such as diagnosis, date of
Operational Definitions admission, date of discharge, patient and family
Modified radical mastectomy (MRM) medical history, risk factors, etc.
Modified radical mastectomy is a removal of the Tool (II) - Shoulder Range of Motion
entire breast in addition to axillary lymph nodes Assessment Questionnaire:
dissection. It was adopted from McRae, (2004) and it was used
Shoulder exercises for modified radical to assess patients' shoulder motion through
mastectomy measuring shoulder range of motion in degrees with
Shoulder exercises are physical activities that are the universal manual goniometer. Elevation through
done by women who had modified radical forward flexion; normal range: 170- 180 degree,
mastectomy to improve their shoulder function. extension; normal range: 50 - 60 degree, abduction;
These exercises include wall hand climbing, rope normal range: 170-180 degree, internal rotation in
turning and rod lifting. abduction; normal range: 50 - 70 degree, external
rotation in abduction; normal range: 90 - 100
degree and adduction; normal range: 50 - 75
Patients & Method degree. Postoperative shoulder motion was assessed
Research design:
as impaired if the range of motion was reduced
A quasi-experimental research design was used in
more than 10 degrees and as full if the range of
this study.
motion was reduced 10 degrees or less compared
Study variables
to the preoperative range of motion (Schultz, et al.,
The independent variable is shoulder exercises
1997). Impaired range of motion was given a score
while the dependent variable is shoulder function
of (1) and full range of motion was given a score of
and shoulder range of motion.
(2).
Setting
Tool (III) - Shoulder Functional Ability
The study was conducted in the surgical oncology
Assessment Questionnaire:
department and surgical outpatient clinic at South
It was adopted from American shoulder and elbow
Egypt Cancer Institute - Assiut University.
surgeons' shoulder evaluation form McRae, (2004)
Patients
and it was used to assess functional abilities of the
A purposive sample of (80) adult female patients
affected shoulder. It was translated into Arabic and
with breast cancer scheduled for modified radical
it includes 13 questions regarding the ability to
mastectomy with mean ages (45.5±11.7) for study
perform specific activities as using the hand
group & (44.8±10.8) for control group. Patients

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overhead, dressing, combing the hair, etc. Each Data collection

activity was evaluated on a scale of 0- 4 and the Data were collected from February 2016 to October
results were summed (0 = unable, 1= only with 2016. The data collection was done through the
assistance, 2 = with difficulty, 3 = mild following phases:
compromise, 4 = normal). Preparatory phase (Assessment phase)
Teaching material (booklet) The researcher interviewed the patients with breast
It was designed to give patients written instructions cancer who were scheduled for modified radical
about shoulder exercises including wall hand mastectomy preoperatively at the surgical oncology
climbing, rope turning and rod lifting, how to department to explain purpose and nature of the
change the dressing and clean the skin around drain study and get their oral consent to participate in the
tubing and signs of wound infection. It was study. Categorization of the patients into two
constructed and filled by the researcher after groups (study and control) (40 patients for each)
passing through an extensive and relevant literature was done.
review in the form of booklet using simple Arabic The researcher collected baseline data from both
language and different illustrated pictures to groups (study and control) using tool (I) part (I, II),
facilitate understanding of its contents. measure shoulder range of motion exercises with
Administrative approval universal manual goniometer using tool (II).
An official permission was obtained from the head Elevation through forward flexion, ask the patient
of South Egypt Cancer Institute at Assiut to swing the arm forward and lift it above the head.
University. View the patient from the side. Backward
 The first tool (structured interview questionnaire) extension, ask the patient to swing the arm directly
was developed by the researcher after extensive backwards, view and measure from the side.
review of the relevant literature. The tool (I) Abduction, measure the range of abduction, in
(structured interview questionnaire) was tested for normal shoulder the arm can touch the ear with
content validity by five experts of academic only slight tilting of the head. Internal rotation in
medical and nursing staff at Assiut University. abduction, abduct the shoulder to 90 degree and
Modifications were done accordingly, and then flex the elbow to the right angle. Ask the patient to
the tool was designed in their final format and lower the forearm from the horizontal plane.
tested for reliability using internal consistency for External rotation in abduction from the same
the tool measured using Cronbach alpha test, the starting position with the forearm parallel to the
tools were proved to be reliable (0.87) ground, ask the patient to raise the hand, keeping
(Acceptable alpha ≥ 0.7). the shoulder in (90) degree abduction. Adduction in
Ethical considerations extension, place one hand on the shoulder and
 Research proposal were approved from Ethical swing the arm, flex at the elbow across the chest. In
Committee in the Faculty of Nursing. addition, functional abilities of the affected
 An oral permission for voluntary participation shoulder were measured by asking the patients to
was obtained from patients and the nature and perform specific activities using tool (III) for both
purpose of the study were explained. groups.
 There is no risk for the study patient during Implementation phase
application of the research. Patients in the study group were interviewed
 The researcher initially introduced herself to all individually by the researcher in the preoperative
patients and they were assured that the collected period at the surgical oncology department for
data would be absolutely confidential. twice and received two sessions for about 40
 Patients were informed that participation is minutes for each. The first session started by
voluntary and that they could withdraw at any explaining the purpose and nature of the study and
time of the study. Confidentiality of the patient’s the objectives of the session then includes oral and
data was ascertained. written instructions about post-mastectomy
 Confidentiality and anonymity were assured. shoulder exercises (wall hand climbing, rope
 Patients’ names were coded for data entry so that turning and rod lifting). The second session usually
their names could not be identified. started by a summary of what had been taught
Pilot study during the previous session and the objectives of
Pilot study was conducted on 10% of the sample (8 the new session then includes oral and written
patients) in the selected setting to evaluate the instructions about how to change the dressing and
applicability & clarity of the tools. According to clean the skin around drain tubing and signs of
this pilot study, the required modifications were wound infection. After each session, there was 10
made. These patients were excluded from the study minutes for discussion and giving feedback.
sample. Reinforcement of teaching was performed
according to patient's needs to ensure their
understanding. Each patient in the study group
obtained a copy of the teaching booklet.

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Patients in the study group were encouraged to use

the affected arm in activities of daily living and
were encouraged to perform postmastectomy
shoulder exercises, demonstration and
redemonstration several times until performance
without error was done.
The study group: this group performed post-
mastectomy shoulder exercises on the second day
postoperatively, two times daily for 20 minutes
each time and continued these exercises at home
after discharge for one month.
The control group: this group received routine
hospital care.
-After discharge, the researcher contacted each
patient in the study group by telephone to be sure
that she was following the given instructions and to
encourage her to follow them and practice the
shoulder exercises continuously on the specified
times.
Evaluation phase
1- Shoulder range of motion and functional abilities
of the affected shoulder were evaluated by the
researcher in the surgical outpatient clinic one week
after starting the exercises for the study and the
control groups and then one month after patients
discharge from hospital for both groups using tool
(II, III) respectively.
Statistical Design
Data entry and statistical analysis were done using
IBM SPSS computer program "version 20.0"
software. The data were tested for normality using
the Anderson-Darling test and for homogeneity
variances prior to further statistical analysis.
Categorical variables were described by number
and percent (N, %). Continuous variables
described by mean and standard deviation (Mean,
SD). Chi-square test used to compare between
categorical variables. T-test used to compare
between continuous variables, statistical
significance was considered at p-value <0.05.
Difficulties of the study
 Level of literacy in patient population limits their
ability to access or benefit from some parts in the
educational booklet because of lack in their
reading ability. To solve this problem, each
patient in the study group was given a copy of all
available mass media as posters, pictures and
brochures.
 Some patients did not attend follow up until the
researcher reminded them about follow up. These
patients were excluded from the study sample. To
overcome that, we replace the excluded patients
by other patients to maintain suitable number of
the study sample (80 patients).

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Results
Table (1): Frequency distribution of Socio-demographic characteristics of both groups (n = 40).
Study (n = 40) Control (n = 40)
Socio- demographic characteristics P. value
n. % n. %
Age
 30 - > 40 years 12 30.0 14 35.0
0.633 ns
 40 - 60 years 28 70.0 26 65.0
Mean ±SD 45.5±11.7 44.8±10.8 0.782 ns
Marital status:
 Married 28 70.0 30 75.0
 Divorced 4 10.0 4 10.0 0.837 ns
 Widow 8 20.0 6 15.0
Level of education
 Illiterate 22 55.0 20 50.0
 Reads and writes 6 15.0 6 15.0
 Primary education 8 20.0 6 15.0 0.788 ns
 Secondary education 2 5.0 4 10.0
 University education 2 5.0 4 10.0
Occupation:

 Housewife 34 85.0 32 80.0

0.556 ns
 Employee 6 15.0 8 20.0
Residence
 Village 30 75.0 26 65.0
0.329 ns
 City 10 25.0 14 35.0
Do you have children
 Yes 40 100.0 40 100.0 -
ns
= Non significant difference (p > 0.05) * Statistically significant difference (p<0.05)
**Highly statistically significant difference (p<0.01)

Table (2): Comparison between the study and the control groups as regards shoulder range of motion (n = 40).

Shoulde Before Operation One week After One month After

r range Study Control P. Study Control Study Control
P. value P. value
of motion Mean±SD Mean±SD value Mean±SD Mean±SD Mean±SD Mean±SD
Elevation
through
172.7±1.4 172.6±1.8 0.778 161.4±4.0 157.4±4.6 <0.000** 163.8±3.8 159.8±4.7 <0.001**
forward
flexion
Extension 51.9±1.5 51.9±1.2 0.871 40.6±3.9 37.3±4.1 <0.000** 43.9±3.5 39.7±4.1 <0.001**
Abduction 171.3±1.4 171.7±1.1 0.192 159.8±4.2 156.6±3.6 <0.000** 163.1±3.7 158.9±3.8 <0.001**
Adduction 52.7±1.7 53.6±1.5 0.012* 41.8±3.04 39.0±4.5 0.002** 44.7±3.0 41.4±4.7 <0.001**
Internal
rotation in 51.5±1.2 51.7±1.2 0.444 40.3±3.6 37.1±4.3 0.001** 43.3±3.5 39.6±4.3 <0.001**
abduction
External
rotation in 91.9±1.5 92.3±1.5 0.195 80.3±3.3 77.1±5.0 0.001** 83.5±2.7 79.9±5.1 <0.001**
abduction
ns
= Non significant difference (p > 0.05) * Statistically significant difference (p<0.05)
**Highly statistically significant difference (p<0.01)

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Table (3): Comparison between the study and the control groups regarding shoulder function.
Before Operation One week After One month
Mean±SD Mean±SD Mean±SD
Shoulder function
P.
Study Control Study Control P. value Study Control P. value
value
Putting the hand
4±0 4±0 1.000 2.05±0.88 1.45±0.93 0.004** 3.55±0.81 2.65±0.98 0.001**
in a back pocket
Washing the
4±0 4±0 1.000 2.15±0.92 1.35±0.92 0.000** 3.55±0.81 2.7±0.91 0.001**
opposite axilla
Combing the hair 4±0 4±0 1.000 1.8±0.94 0.9±0.9 0.000** 3.35±0.8 2.5±0.82 0.001**
Carrying 4.5 kg
4±0 4±0 1.000 1.35±0.92 0.55±0.88 0.000** 2.6±0.81 1.6±0.74 0.001**
at the side
Sleeping on the
4±0 4±0 1.000 2.05±0.81 1.45±0.99 0.004** 3.65±0.66 3.1±0.84 0.002**
affected side
Using the hand
4±0 4±0 1.000 2.45±0.81 1.5±0.88 0.000** 3.6±0.81 2.85±0.98 0.001**
over head
Lifting 4±0 4±0 1.000 2.05±0.93 0.95±0.75 0.000** 3.1±0.71 2.1±0.84 0.001**
Perineal care 4±0 4±0 1.000 2.55±0.81 1.45±0.81 0.000** 3.65±0.66 2.85±0.98 0.001**
Eating with
4±0 4±0 1.000 2.75±0.63 2.05±0.68 0.000** 3.75±0.44 3.4±0.5 0.001**
utensil
Using the arm at
4±0 4±0 1.000 2±0.85 1.35±0.66 0.000** 3.15±0.74 2.5±0.68 0.001**
shoulder level
Dressing 4±0 4±0 1.000 2.5±0.88 1.5±0.88 0.000** 3.65±0.74 2.8±0.94 0.001**
Pulling 4±0 4±0 1.000 2.15±0.92 1.25±1.01 0.000** 3.45±0.81 2.8±0.88 0.001**
Throwing 4±0 4±0 1.000 1.45±0.81 0.7±0.85 0.000** 2.7±0.91 2.05±0.81 0.001**
Total mean score
of shoulder 52±0 52±0 1.000 27.3±10 16.5±9.9 <0.001** 43.7±8.9 33.9±10.2 <0.001**
function
ns
= Non significant difference (p > 0.05) * Statistically significant difference (p<0.05)
**Highly statistically significant difference (p<0.01)

Table (4): Relation between the outcome of the shoulder function and demographic characteristics (age
and residence) of the study group (n=40).
Age Residence
Shoulder function 30 - ˂40 years 40- 60 years P. value Village City P. value
n. % n. % n. % n. %
Before operation
Normal 12 100.0 28 100.0 - 30 100.0 10 100.0 -
After one week
Only with assistance 2 16.7 12 42.9 10 33.3 4 40.0
0.112 ns 20 66.7 6 60.0 0.702 ns
Mild compromise 10 83.3 16 57.1
After one month
With difficulty 0 0.0 8 28.6 6 20.0 2 20.0
0.038* 1.000 ns
Normal 12 100.0 20 71.4 24 80.0 8 80.0
ns
= Non significant difference (p > 0.05) * Statistically significant difference (p< 0.05)
**Highly statistically significant difference (p< 0.01)

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Table (5): Relation between outcome of shoulder function and demographic characteristics (level of
education and occupation) of the study group (n=40).
Level of education Occupation
Reads
Shoulder Primary Secondary University
Illiterate and P. value Housewife Employee P. value
function education education education
writes
n. % n. % n. % n. % n. % n. % n. %
Before operation
Normal 22 100.0 6 100 8 100.0 2 100 2 100 - 34 100 6 100 -
After one week
Only with
8 36.4 0 0.0 4 50.0 0 0.0 2 100.0 10 29.4 4 66.7
assistance 0.065 ns 0.078 ns
Mild compromise 14 63.6 6 100 4 50.0 2 100 0 0.0 24 70.6 2 33.3
After one month
With difficulty 4 18.2 0 0.0 4 50.0 0 0.0 0 0.0 4 11.8 4 66.7
0.134 ns 0.002**
Normal 18 81.8 6 100 4 50.0 2 100 2 100 30 88.2 2 33.3
ns
= Non significant difference (p > 0.05) * Statistically significant difference (p< 0.05)
**Highly statistically significant difference (p< 0.01)

Figure (1): Frequency distribution of the outcome of shoulder function of both groups.

Table (1): Showed that more than half of women in both groups (70% and 65%) respectively, their ages ranged
between (40 to 60) years with mean ages compared to the control group regarding shoulder
(45.5±11.7) for the study group & (44.8±10.8) for range of motion in (elevation through forward
the control group. Most of the women in the study flexion, extension, abduction, adduction, internal
and the control groups were married and illiterate rotation in abduction and external rotation in
(70%, 75% and 55%, 50%) respectively. Regarding abduction) one week and one month after starting
occupation, the majority of the women in both the exercises (p<0.01).
groups were housewives (80% and 85%) Table (3): Clarifies that there was a highly
respectively. More than half of the women in the significant improvement in the study group
study and the control groups (75 % and 65%) compared to the control group regarding shoulder
respectively were living in rural areas. As regard to function one week and one month after starting the
having children, all of the women in both groups exercises (p<0.01).
had children. Finally, the table illustrated that there Table (4): Illustrated that there was a significant
was no statistical difference between the study and relation between the outcome of the shoulder
the control groups regarding sociodemographic function and ages of the study group after one
characteristics (p > 0.05). month (p<0.05). In addition, the table showed that
Table (2): Revealed that there was a high there was no significant relation between the
significant improvement in the study group

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outcome of the shoulder function and residence of highest educational level had increased incidence of
the study group (p > 0.05). breast cancer when compared to the women with
Table (5): Clarified that there was no significant lower education.
relation between outcome of shoulder function and Regarding occupation, the majority of the women in
level of education of the study group (p > 0.05). In both groups were housewives. It could be due to
addition, the table illustrated that there was high rate of illiteracy among Egyptian women. This
significant relation between outcome of shoulder result was in agreement with Azeaz, et al., (2013),
function after one month and occupation of the who reported that most of both groups were
study group (p<0.05). housewives. In addition, this study finding was in
Figure (1): Revealed that all women in the study accordance with Sallam, et al., (2013), who
and the control groups had normal shoulder function presented that the majority of the studied women
before operation. More than half of the study group were housewives. Regarding residence area, more
(65%) had mild compromised shoulder function than half of the women of the study and the control
while most of the women in the control group groups were living in rural areas. This finding was
(75%) need assistance in performing the shoulder in agreement with Bahgat, et al., (2016), who
function one week after starting exercises. Most of reported that about half of the study group and more
the study group (80%) had normal shoulder function than half of the control group were residence in
while (60%) of the control group had difficulty in rural areas.
performing the shoulder function one month after Regarding shoulder range of motion and shoulder
starting exercise. Finally, the table showed that function, the present study revealed that there was a
there was a highly significant improvement in the highly significant improvement in the study group
study group compared to the control group compared to the control group one week and one
regarding the shoulder function one week and one month after exercises start (p<0.01). This means
month after starting exercises (p<0.01). that the study group restored full shoulder range of
motion and attained shoulder function more than the
Discussion control group after applying shoulder exercises
Based on the results of the present study, more than following surgery. This means that shoulder
half of the women in both groups, their ages ranged exercise that was taught had a positive effect in
between (40to 60) years with mean ages improving shoulder function and helping patients to
(45.5±11.7) for the study group & (44.8±10.8) for return to their previous level of performance in
the control group. This means that both the immune work and daily life, if the patient practices them
response and the hormonal changes altering with regularly.
aging are associated with breast cancer. This finding This result was supported by Azeaz, et al., (2013),
was in the same line with Ibrahim, et al., (2012), who reported that there was a significant
who concluded that, more than half of the studied improvement in shoulder function in the study
women were ranging between 40 to less than 60 group in the short term than the control group post
years old. Also, Azeaz, et al., (2013), mentioned program and after one month of implementation of
that the mean age of the women in both groups was the educational program (shoulder exercises).
45.25 ± 5.86 for the study group and 46.06 ± 6.19 Moreover, Fung et al., (2011), mentioned that
for the control group. physiotherapy and rehabilitation program was
Regarding marital status, most of the women of the proved to be efficient and safe in restoring the full
study and the control groups were married. This range of motion of shoulder and arm and improving
result was in agreement with Bahgat, et al., (2016), shoulder function without any complications. Also
who mentioned that the majority of the women in Keays, et al., (2016), showed that the greatest
studied groups were married. improvement in shoulder range of motion followed
In relation to the educational level, most of the implementation of the intervention.
women in both groups were illiterate and more than This result was also corresponding with Park, et
half of the women in both groups were living in al., (2006) & Bahgat, et al., (2016), who revealed
rural areas. This is due to the fact that illiteracy rate that the greatest improvement in internal rotation,
is higher among women in Egypt accounting (69%) external rotation and flexion of shoulder occurred in
of the total number of illiterate people in Egypt. the study group when compared to the control
This result was in accordance with Ibrahim, et al., group. In addition, Keays, et al., (2016), revealed
(2012), who reported that more than one third of the that a significant improvement in shoulder range of
study group and one-half of the control group were motion in abduction, flexion and external rotation
illiterate. This finding contradicted with Beiki, et followed implementation of the educational
al., (2012), who revealed that women with the

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program in the study group compared to the control This finding was in the same line with Shaaban,
group. (2013), who reported that therapeutic exercise has
This finding is in consistent with Chan, et al., many benefits for all the patients after operation.
(2010), who revealed that there was a significant Exercises are important to prevent contracture of the
improvement in shoulder mobility and shoulder joints, shortening of the muscles and to improve
function in the study group. Moreover, the lymph and blood circulation after mastectomy.
improvement in measurements of abduction and Moreover, self-care activities, such as combing the
flexion movements of the shoulder was statistically hair, washing the face and brushing the teeth are
significant better in the study group. physically and emotionally therapeutic because they
Moreover, Sallam, et al., (2013), revealed that aid in returning and restoring the shoulder function
shoulder exercises improved shoulder range of and the sense of normalcy for the patients after
motion in internal rotation and extension in both mastectomy (Hinkle & Cheever, 2014).
studied groups but there was no significant Lauridsen, et al., (2016), was in the same line with
difference between early and delayed shoulder the present study revealing that physiotherapy
exercises. Moreover, Lotze, et al., (2011), reported significantly improves shoulder function for breast
that sufficient functional range of motion was cancer patients treated surgically. Moreover,
attained in all patients without major complications Chung, et al., (2013), mentioned that physical
after applying postmastectomy shoulder exercises, therapy is useful for shoulder range of motion when
but there were no significant differences between performed early after surgery. Any type of exercise
the patients receiving early or delayed exercises could improve shoulder mobility, shoulder function,
postoperatively at any time interval (1, 3, 6 months). and shoulder range of motion, in short period.
This finding was matched with McNeely, et al., This result is in line with Fung, et al., (2011), who
(2010), who found that upper limb exercise (e.g. concluded that physiotherapy program was proved
shoulder range of motion) is useful in recovering to be useful in recovering and improving shoulder
and improving upper limb movement and improves function with minimum complications. Also, Brito,
shoulder range of motion after surgery for breast et al., (2012) & Gautam, et al., (2011), reported
cancer patients. Starting exercise early after surgery that to prevent shoulder dysfunction, reduce the
(first day to third day) may result in the greatest impairment of strength and mobility of shoulder and
improvement in shoulder movement in the short to avoid lymphoedema after mastectomy,
term and it is useful to regain shoulder movement postmastectomy shoulder exercises are usually
and its use for daily activities such as reaching prescribed.
overhead. The results of the current study revealed that there
These results were consistent with Loh & Musa, was a significant relation between the outcome of
(2015), who reported that exercises rehabilitation the shoulder function and ages of the study group
showed a significant improvement in shoulder after one month. This means that the younger
movement with early exercises more than the patients had more improvement in shoulder function
delayed ones. Moreover, Galantino & Stout, when compared to the group of the older patients.
(2013), reported that early physiotherapy especially Also, incidence of shoulder dysfunction and
postmastectomy shoulder exercises is a common restricted shoulder mobility increases with aging
treatment to prevent shoulder dysfunction and due to altered immune response with aging,
restricted shoulder mobility. Nurse or physical decreased ability to perform specific activities as
therapist can suggest and perform shoulder combing the hair and using the hand overhead, and
exercises that help to improve and regain movement decreased ability to do postmastectomy shoulder
and strength in arm and shoulder without any exercises regularly.
complications and improve quality of life. This finding was in agreement with Azeaz, et al.,
Also, Gautam, et al., (2011), Azeaz, et al., (2013) (2013), who revealed that there was a significant
& Mahdy, (2014), mentioned that full range of relation between patient’s age and Shoulder Pain
motion returns after proper postmastectomy and Disability Index (SPADI) scores post program
shoulder exercises. Both arms can be extended fully and after one month of implementation of
and equally high over the head. The woman benefits intervention. This means that the group of younger
from having something active to do to help herself patients had less SPADI score than the older ones.
during the hard time of adjustment after modified Finally, it can be concluded that applying shoulder
radical mastectomy. Many activities of daily living exercises for patients undergoing modified radical
provide good exercise, such as hanging clothes, mastectomy is considered a corner stone in
reaching high shelves, and gardening. improving shoulder function and restoring the full
range of motion of shoulder and arm.

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Conclusion Breast cancer: rehabilitation. Acta Fisiatr, Vol.

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