Abstract

Effectiveness of early  rehabilitation on range of  motion, muscle strength  and arm function after breast  cancer surgery: a systematic  review of randomized  controlled trials

Ivana Leão Ribeiro1,2 , Roberta Fátima Carreira Moreira2, Angélica Viana Ferrari2, Francisco Alburquerque-Sendín3,4, Paula Rezende Camargo2  and Tania Fátima Salvini2. Clinical Rehabilitation 2019, Vol. 33(12) 1876 –1886

Objective: The objective was to evaluate the effectiveness of early rehabilitation on arm range of motion (ROM), strength and function after breast cancer surgery (BCS). Data sources: PubMed, MEDLINE, Bireme, Embase, LILACS and CINAHL databases were searched.

Methods: Two independent reviewers selected randomized controlled trials evaluating women who underwent early rehabilitation to restore arm ROM, strength or function after BCS. Cochrane Collaboration recommendations and Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) guidelines were followed. Methodological quality was assessed by the PEDro scale. The International Classification of Functioning, Disability and Health was considered to analyze results. Effect size (ES) was calculated for clinical relevance interpretation of the outcomes of interest, and the evidence was summarized through the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

Results: Up to June 2019, a total of 1658 references were identified and 15 studies were included. Twelve of them presented adequate methodological quality. A total of 1710 patients were evaluated. Few studies performed the simultaneous assessment of variables related to body structure and function and patient-reported outcomes. A moderate level of evidence was synthesized regarding the effectiveness of ROM exercises for improving arm flexion, abduction and external rotation (ES: 0.45–2.5). A low level of evidence was synthesized regarding the effectiveness of isolated strengthening exercises for patient reported arm function. ROM exercises associated with muscle strengthening exhibited a moderate level of evidence for improving shoulder flexion (ES: 1.4–2.4).

Conclusion: Both ROM and strengthening exercises associated with ROM exercises improved shoulder flexion, abduction and external rotation ROM after BCS. Shoulder abduction and external rotation showed less recovery, irrespective of the intervention applied.

Main findings

• This systematic review aimed at evaluating the effectiveness of early rehabilitation protocols on range of motion, muscle strength and arm function after breast cancer surgery.
• A moderate level of evidence was identified regarding the effectiveness of protocols that used range of motion exercises to improve shoulder flexion, abduction and external rotation range of motion after a three-month follow-up.
• The evidence was also moderate for protocols that associated range of motion exercises with strengthening exercises to enhance shoulder flexion after three- and six-month follow-ups.
• A low level of evidence was identified regarding the effectiveness of the range of motion exercises, muscle strengthening exercises and range of motion exercises associated with muscle strengthening.
• Although the majority of study protocols were started in the first week following surgery,7,26–37 the exercises used were heterogeneous, as were the frequency and duration of the sessions and total treatment duration. The evaluation tools used in the studies were also heterogeneous. Another critical point is related to the follow-up periods, which ranged from the five postoperative days to 12 months after surgery.
• The analysis of 10 studies including 825 patients revealed a moderate level of evidence regarding the effectiveness of the range of motion exercise protocols for range of motion flexion, abduction and external rotation in the three-month follow-up, with moderate to high ES.
• On the other hand, a low level of evidence was observed for the effectiveness of this type of intervention in improving upper limb function reported by patients and assessed through questionnaires, after the analysis of five studies.
• The heterogeneity of the exercise protocols regarding the type of training, session’s frequency and duration as well as the total duration of the protocols applied associated with the different results obtained after treatments are also important factors that led to the low level of evidence synthesized by the GRADE system.
• After the analysis of four studies28,32–34 involving 661 participants, a low level of evidence was synthesized regarding the effectiveness of muscle strengthening exercises for upper limb function improvement at three months of follow-up.
• Limitations:
  • Internal validity, the allocation concealment, blinded evaluation of the outcomes and inclusion of intention-to-treat analysis deserve researcher’s attention for future studies’ design.
  • External validity, there was also a lack of detailed information on the protocol used, such as session frequency, treatment duration and lack of ES and CI measure’s presentation. Future studies should be conducted considering these gaps, so that more conclusive evidence can be summarized regarding the effectiveness of early rehabilitation programs in restoring shoulder range of motion, strength and upper limb function in the immediate postoperative period of individuals submitted to breast cancer surgery.
• Clinical messages from the authors:
  • In patients who have had surgery for breast cancers, range of motion protocols associated with strengthening exercises may improve shoulder flexion, abduction, range of external rotation and arm function.
  • There is little evidence regarding frequency, intensity, the exact type of exercise or duration of treatment.