Effect of an instructional scheme on post
mastectomy
exercises in breast cancer
Dr Shereen A Qalawa 1, Prof Sanaa M Alaa Elden 2, Enas I El-Sheikh 3, Prof Hoda W El-Gawly 4, Prof Ahmed M Elzawawy 5.
1Department
of Medical-Surgical Nursing, Faculty of Nursing, Suez Canal University
2 Departments of Adult Nursing, Faculty of
Nursing,
Alexandria, Egypt
3 Department of public health and preventive
Medicine,
Faculty of Medicine, Suez Canal University, Egypt
4 Department of Pharmacology, Faculty of
Medicine,
Suez Canal University, Egypt
5 Clinical Oncology, Faculty of Medicine, Suez Canal University,
Egypt
Corresponding
author: Dr Shereen A Qalawa, Department of Medical-Surgical Nursing,
Faculty of
Nursing, Suez Canal University , Email: shereen.q066@yahoo.com
Afr J Haematol
Oncol 2011;2(2):197-201
ABSTRACT
AIM To
study the effect of implementing an instructional scheme for
mastectomised women regarding post mastectomy exercises in breast
cancer.
METHODS Fifty-four female patients were studied at the oncology clinic of Port-Said General Hospital in Port-Said city, Egypt. A one-group pretest-posttest pre-experimental research design was used to conduct this study, with pretest, posttest and follow-up assessments. The assessments were used to evaluate the effect of an implemented instructional scheme for mastectomised breast cancer women in improving knowledge and practice towards arm exercises.
RESULTS There
was significant improvement
in patients’ knowledge on the importance of arm
exercises post-mastectomy following implementation of the instructional
scheme
from 53.7% to 100%. Non compliance with exercises also significantly
declined
following the implementation of the instructional scheme.
CONCLUSIONS Implementation of
an-instructional scheme
for mastectomised breast cancer patients is useful in increasing and improving patients’
level of knowledge and compliance with exercises.
Keywords: Instructional models; Mastectomy; Exercise; Breast cancer; Egypt.
INTRODUCTION
Breast
cancer is the most common
and the third most frequent cancer among women in the world.
1 In Egypt the number of new cancer
patients per year was estimated to be 65,000 in 2001. 2
Accumulated
patients represent about three times the number of new cases. The
number of
cancer patients in Egypt is expected to increase as the population
continues to
grow and age, and as the prevalence of known etiological factors
increases.
3 Surgical treatment is the
oldest and
usually the first line of treatment for solid cancers. Surgery for
breast
cancer is often followed by adjuvant chemotherapy and radiation. These
predispose patients to additional complications such as:
lymphoedema, infection, seroma
and cellulitis. 4-5 Lymphoedema
after breast
cancer treatment occurs, on average, in 30% of patients at risk. 6 The high incidence of breast
cancer makes post mastectomy complications a significant topic. 7-8
The
prevalence of lymphoedema in
the United States is estimated at 2.5 million, and 10 million people
are
affected worldwide. Complications like lymphoedema impact quality of
life and
functional ability as well as body image, self esteem, and social
standing. 9 Effective
management requires a knowledge base regarding the epidemiology,
prevention, and treatment of these complications. Early
physiotherapy administered by experienced physiotherapists could
be an effective intervention in the prevention of secondary
lymphoedema. 10 Physical
exercise may also improve shoulder mobility which may in turn improve
physical
functioning and cardiopulmonary activity. 11 Other benefits
of
physical exercise include improvement in quality of life outcomes and
control
of weight gain. 12-13 Physiotherapist-based services are
costly, 14
more so within the settings of limited resources. As such it is
desirable to
explore ways to motivate patients to carry out home-based,
self-administered
exercise programmes.
This
study was carried out to
design, implement and evaluate an instructional scheme for the prevention of
complications in breast cancer women post-mastectomy.
METHODS
The
design for this study was a one-group
pretest-posttest pre-experimental
research
design with
pretest, posttest and follow-up assessments to evaluate the effect of
implementing an instructional scheme to improve the knowledge and
practice of
mastectomised women towards post mastectomy exercises. Study patients
included
54 women from the oncology clinic of Port-Said General Hospital in
Port-Said
city with the following criteria: (1) female patients 2 weeks after lumpectomy, modified radical, standard radical,
extended
radical mastectomy with axillary node
dissection, or
simple mastectomy with axially lymph node dissection; and (2) received
radiotherapy and chemotherapy.
Data
was collected using three
tools. Tool I – patient interview: a questionnaire was
designed by the study
team based on literature review. It was constructed in simple Arabic
language
to facilitate understanding by all study participants. It took 20-30
minutes
for participants to complete the questionnaire. Tool II
- observational checklist of exercises: this assessed
patients’ actual performance of exercises that prevented
complications like
lymphoedema. It was developed based on Ann et al (2001) 15 and Hess (2006). 16
It included 11 forms of exercises in different positions as follows:
(1)
shoulder roll in standing or sitting position; (2) front bar lift in
standing
or sitting position; (3) front bar side push in standing position ; (4)
back
bar side push in standing position; (5) side triceps extension in
sitting or
standing position; (6) side lying horizontal arm lift while lying on
unaffected
side with head on small rolled towel or cushion; (7) shoulder rotation
stretch
in standing position; (8) shoulder down, neck straight, and abdomen in,
forward
ball stretch in prone position with knee on floor with Swiss ball in
front of
the patient; (9) single leg raises lying on back with small cushion or
rolled
towel under head on firm bed or floor; (10) prone butterfly exercise
for
posterior shoulders in knee on floor flexed with Swiss ball in front of
the
patient; and (11) deep abdominal or diaphragmatic breathing exercises
in supine
positions with double leg curl or bent on floor or ball. Tool
III - The instructional
scheme: based on
patients’ knowledge and practice assessment in pretest and review
of related
nursing literature.
The study was covered in four phases: pretest, instructional scheme planning, instructional scheme implementation and evaluation phases. During the pretest phase assessment of patient's knowledge and practice about prevention of arm lymphoedema was done using tools I and II. The instructional scheme planning phase involved development of the scheme as described above using the base line information gathered in phase I, it was improved by retesting and checking cycles. Checking was done by an oncologist and two nursing professors with relevant expertise. Instructional scheme implementation was done in 6 groups of 7-9 patients each group. The phase lasted three months at a rate of one session per week. Each session took about 1 hour a day according to availability of study participants in the period 7 July to 5 October 2007. The instructional scheme was presented in a clear and concise form, and was focused on the point of learning, using different teaching methods such as discussions and demonstrations. A booklet, a pamphlet , wall charts, and various teaching objects were used. The impact of the developed instructional scheme was evaluated 2 times first at 3 months then at 6 months after the instructional scheme implementation.
Data
from data collection sheets
was cleaned and graphs were drawn using Microsoft excel 2007.
Descriptive and
analytical data analyses were carried out using statistical package for
social
sciences (SPSS). A p-value of less than 0.05 was considered
significant. Chi
square Fisher’s exact tests were used as appropriate.
RESULTS
The
50-59 age group
had the highest number of participants (43.4%), Table 1.
All participants were housewives. A large
number (32.6%) were illiterate. All had
had the diagnosis of breast cancer for less than a year and it was
their first
time to undergo breast surgery. Four (7.4%) of the patients developed
lymphoedema post-surgery and half of these were from the illiterate
group.
There
was significant
improvement in patients’ knowledge of the importance of arm
exercises
post-mastectomy following implementation of the instructional scheme.
In the
pretest assessment, 53.7% of the participants agreed that arm exercises
were
useful in preventing complications like lymphoedema and in the posttest
assessment 100% of the participants agreed (Table 2).
Compliance with exercises also significantly
improved (Table 2).
Non
compliance with exercises
significantly declined following the implementation of the
instructional scheme
(Table 3).
Table 2:
Comparison between pretest,
posttest and
follow-up periods regarding patients’
knowledge
towards arm exercises. |
DISCUSSION
The percentage of lymphoedema complications in this study is comparable to previous studies, one of which - using strict methods of measurement of limb volume - detected acute lymphoedema at 3 months in 5% of the sample, and at 6 months in 11% of the sample. 15 Another study found a high percentage of mild degree of lymphoedema (42.5%), 25% for moderate and 15% for severe degree of lymphoedema after 3 months postoperatively . 17 Lymphoedema may be underestimated after breast cancer surgery. 18 It is estimated that as many as 60% of breast cancer survivors report symptoms of lymphoedema.
Concerning patients’ knowledge and practice towards arm exercises post mastectomy, the present study found significant improvement between pre, post and follow-up after implementation of the instructional scheme. This finding is encouraging in view of the findings of Mcwayne and Heieny (2005) that an educational program in the prevention of arm lymphoedema directly promotes patient's quality of life. 19 Exercises might be difficult soon after surgery as the body might be weak but they are an important part of an active and health life style, breast cancer survivors can benefit on two fronts by giving themselves a workout while helping to prevent complications like lymphoedema at the same time. 20 Exercises also help with radiotherapy treatment in hand positioning, increased arm flexibility and decreased arm pain.
CONCLUSION
Implementation of an-instructional scheme for mastectomised breast cancer patients is useful in increasing and improving the patient's level of knowledge and compliance with exercises. More studies are required to explore what the best media should be for such instructional schemes as well as the local social, oncology and psychological contexts.
FOOTNOTES
Conflicts
of
interest: The authors declare no
competing conflicts of interest.
REFERENCES
1. Lim EK. Medicine And Surgery: An Integrated Textbook . 1st ed. Philadelphia: Churchill living stone Elsevier. Page 100-102. 2007.
2. Elatter I. Cancer Registration, NCI Egypt 2001. Available at:- http://www.nci.edu.eg/Journal/nci2001%20.pdf (accessed 30 June 2011)
3. Gab-alla S. Quality of life in cancer patients under chemotherapy. Unpublished Masters Thesis, Faculty of Nursing, Suez Canal University, Egypt. Page 54. 2003
4. Bare BG. Adult health nursing. 2nd ed. Philadelphia: Mosby Co. Page 498. 1994.
5. Abu-El ATR. Impact of chemotherapy on post – mastectomy women. Unpublished Doctorate thesis, Faculty of Nursing, Suez Canal University. Egypt. Page 11-15. 2001.
6. Harvey B, Best L, Irwin M, David M, William L. Debilitating Lymphoedema of the Upper Extremity After Treatment of Breast Cancer. American Journal of Clinical Oncology. 2002;25(4):365-367.
7. Suzuba
A, Rockson S. Lymphoedema.
Nuclear Medicine Journal. 2003;44(1):143-57
8. Podcast P. After treatment of breast cancer: preventing Lymphoedema , American Cancer Society. American Journal of Surgery. 2001;6(1):5
9. Carter B. The treatment of lymphoedema related to breast cancer. American Journal of Surgery. 2003;22(8):6.
10. Lacomba MT, Sanchez MJY, Goni AZ et al. Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: randomised single blinded, clinical trial. BMJ 2010;340:b5396
11. Chan DNS, Lui LYY, So WKW. Effectiveness of exercise programmes on shoulder mobility and lymphoedema after axillary lymph node dissection for breast cancer: systematic review. JAN. 2010;66(9):1902–1914.
12. McKenzie DC, Kalda AL. Effect of upper extremity exercise on secondary lymphedema in breast cancer patients: a pilot study. JCO 2003;21:463–466.
13. Kirshbaum M. Promoting physical exercise in breast cancer care. Nursing Standard 2005;22:41–48.
14. Cheville A. Prevention of lymphoedema after axillary surgery for breast cancer. BMJ 2010;340:b5235.
15. Ann K, Christine R, Prathima K et al. Surgical outcomes after breast cancer surgery: Measuring acute lymphoedema. Surgical Research Journal. 2001;95(2):147-151.
16. Hess C. How can I get started on exercise program ? Lymphoedema a breast cancer patient's guide to prevent lymphoedema and health program. Exercising for a healthy heart Journal. 2006;12(1):1.
17. El – Mezewedy M. Assessment of quality of life of females with mastectomy at Cancer Institute of Tanta University and Shebin El-Kom University Hospital . Unpublished masters thesis, High Institute of Nursing, Minoufeya University, Egypt. Page 101. 1999.
18. Paskett D, Naughton J, McCoy P. The epidemiology of arm and hand swelling in premenopausal breast cancer survivors. Cancer Epidemiol Biomarkers Preview Journal. 2007;16(4):775-82.
19. McWayne
J, Heiney
S. Psychologic and social sequelae
of
secondary lymphoedema. Cancer journal. 2005;104(3):457 – 466.
20. Bicego D, Brown K, Ruddick M, Storey D, Wong C, Harris SR. Exercise for women with or at risk for breast cancer-related lymphoedema. Physical Therapy. 2006;86(10):1398-1405.