1. INTRODUCTION:

Breast cancer is one of the most cancers in women worldwide that have severe physical and emotional effects Sharif Nia et al., 2017¹. About 1.7 million new cases and 522,000 deaths occur each year from breast cancer Torre et al., 2015². Breast cancer is considered the most common cancer among women that representing 25% of all cancers Ferlay et al., 2010³.

According to the statistics of World Health Organization breast cancer representing about 30% of all types of cancers among women with the highest rate will be in Eastern Mediterranean countries in the next 15 years. The mortality rate from breast cancer is 70% in Eastern Mediterranean countries, which is higher than that of the developed countries that is estimated by 40-55%⁴.

Diagnosis of breast cancer is considered a very stressful life event for women as this associated with distressing symptoms starting from diagnosis and continue for year or more until completing cancer treatment that follow by dysfunction and impairment of body function due to adjuvant therapy in addition to reducing shoulder movement, pain and lymphedema related to surgical management which in turn affect on patients' functional status from all aspects of life^5,6."According to the World Health Organization’s International Classification of Functioning, Disability and Health, function is defined as the interactions between an individual, their health condition and the social and personal context in which they live. It is the complex interaction between these factors that determines function and impairment"^7,8.

Fann et al., 2008⁹ concluded that the majority of breast cancer patients frequently complain of depression as a result of diagnosis and treatment modalities which leads to disability of the functional status and poor adherence to treatment. Another Results from a systematic review represented prevalence of complications of upper limb after breast cancer surgery which include; range of motion exercises impairment of the shoulder less than one to sixty seven percent, weakness in arm from nine to twenty eight percent, pain in shoulder from nine to sixty eight percent and lymphedema from zero to thirty four percent¹⁰. Also Armer and Stewart, 2010¹¹and Hayes et al., 2012¹² found that lymphedema is considered common complication following breast cancer surgery and radiation therapy that leading to affected arm impairment and shoulder dysfunction as a result of presence of persistent symptoms such as stiffness, numbness, pain and weakness.

Postoperative education for lymphedema prevention is very important for reducing upper arm complications and shoulder dysfunction in addition to improving patients functional status and performing daily activities that affect positively on physical and psychological state¹³. Woods et al 1995¹⁴ reported that eighty one percent of women that have lymphedema complained from psychological and psychosocial problems as a result of breast cancer' treatment and lymphedema formation than breast cancer women who didn't have lymphedema. It is explicit from the above that many women present with complications and dysfunction of upper limb that may still for many years following breast cancer treatment modalities which have a negative impact on functional status and quality of live. So the present study aimed to assess functional status and knowledge after application of lymphedema prevention principles among women post mastectomy.

1.1. Significance of the Study:

Breast cancer women complain from physical and psychological problems related to diagnosis and treatments. Lymphedema is one of the most common and serious problem following mastectomy which may affect on patients' shoulder function and functional status so application of lymphedema prevention principles is very important for improving knowledge, functional status and shoulder function among women after mastectomy.

1.2. Aim of Study:

This study aimed to assess shoulder function, functional status and knowledge after application of lymphedema prevention principles among women post mastectomy.

1.3. Research Hypotheses:

A. Knowledge related to lymphedema prevention principles will be increased for study group than control group among women post mastectomy.

B. Shoulder function and functional status will be improved in study group than control group after application of lymphedema prevention principles among women post mastectomy.

2. METHODOLOGY:

2.1. Research design:

Quasi-experimental research design was utilized to achieve the aim of the study.

2.2. Research setting:

The study was conducted at oncology departments in the University Hospital at Shebin El-kom District, Menouﬁa Governorate, Egypt.

2.3. Subjects:

A purposive sample of 210 female patients post mastectomy was selected by using the following Equation: Sample size n = [DEFF*Np(1-p)]/ [(d2/Z21-α/2*(N-1)+p*(1-p)] that alternatively and randomly assigned into 2 equal groups each one of 105 patients: Group I (study group): were exposed to lymphedema prevention principles in addition to routine hospital care. Group II (control group) was exposed to routine hospital care only. Both groups were matched as much as possible as regards to age, level of education and stage of breast cancer as possible.

The Inclusion criteria were:

Ÿ Adult, conscious and agree to participate in the study.

Ÿ First or second stage of breast cancer.

Ÿ After surgical treatment of breast cancer.

Ÿ No signs of recurrence.

2.4. Instruments of the study:

Instrument (1): A structured Interviewing questionnaire:

It was developed by the researcher after reviewing the related literature and consisted of three parts.

Part I: Sociodemographic data including patient’s age, the level of education, occupation and income.

Part II: Medical data including presence of chronic disease, types of chronic diseases, family history of cancer and treatment modalities.

Part III:

Knowledge related to lymphedema prevention principles as definition of lymphatic system and lymphedema, causes, signs and symptoms, prevention and management of lymphedema. This part contains six items.

Scoring system: Each item was given a score of two marks for the complete correct answer, one mark for the incomplete correct answer and zero for the incorrect answer.

Instrument (2): Shoulder functional ability assessment questionnaires:

It was adopted from American shoulder and elbow surgeons' shoulder evaluation from (McRae, 2004)¹⁵, it was comprised of 13 questions related to the ability for performing special activities such as combing the hair, dressing, using hand over head, etc. each activity was evaluated on a scale of 0-4 and the results were summed 4= normal, 3= mild compromise, 2= with difficulty, 1= only with assistance, 0= unable. Total scores was calculated as 52 – 39= normal, 39 – 26= mild compromise, 26 – 13= performing activities with difficulty, 13= performing activities only with assistance, 0= unable to perform activities.

Instrument (3): Inventory Functional Status Cancer Assessment Scale:

It was developed by Tulman et al., (1991) ¹⁶ and translated to Arabic format by Mohamed, (2001) ¹⁷. It was comprised of 39 items to measure functional status according to its four subscales that had relevant for cancer patients.

1. Personal care activities consists of 10 items as bathing, dressing, eating, exercising, relaxing, resting, walking and sleeping.

2. Household and family activities consist of 15 items like cleaning, cooking, shopping and caring for spouse and children.

3. Occupational activities consist of 8 items such as amount of work accomplished at jop, amount of job responsibility and hours of work.

4. Social and community activities consist of 6 items as participation in community and religious organization, socialization with friends and relatives and time spent on hobbies.

All items of personal care activities and occupational activities subscales were rated from 0 – 4 point rating scale that ranging from one that indicate never to four that indicate all of the time. While household and family activities subscale using other a four point rating scale that ranging from one means not at all to four means full time. The total scale scores ranged from 39 to 156, the higher scores indicates higher functional ability status.

Validity and reliability of tools:

All tools were tested for content validity for content validity by a panel of experts in the field including nurse educators and a medical specialist to ascertain relevance and completeness. The required modifications were done accordingly.

Reliability of tools was done by using test-retest method. It was 92.7for instrument one part three, 90.4 for instrument two and 98.5 for instrument three.

2.5. Data collection:

Data collection of the study was carried out from August 2017 to February 2018. Once permission was obtained to conduct the study, the researchers were initiated data collection.

Ethical Consideration: Permission was taken from the hospital authorities of Menoufia University Hospital for conduction of the study and an informed consent was obtained from participants who accept to participate in the study. The researchers emphasized that participation is entirely voluntary and anonymity and confidentiality were achieved.

A pilot study was carried out on 10 % of patients representing the study sample to test the feasibility and clarity of instruments used and modifications were done accordingly. Patients used in the pilot study were excluded from the total study sample.

A purposive sample of 210 female patients post mastectomy was randomly assigned alternatively into two equal groups (study and control) each one consists of 105 patients. The study group was received lymphedema prevention principles and routine hospital care. Control group received routine hospital care only.

The study was conducted in four steps: assessment, planning, implementation and evaluation.

Assessment:

The researchers initiated data collection after introducing themselves to the subject who fulfilled the inclusion criteria and agreed to participate in the study then assessed baseline data of patient's sociodemographic, medical data and knowledge related to lymphedema prevention principles using instrument (I). In addition to Shoulder functional ability by using instrument (II) and functional status by using instrument (III).

Planning:

The researchers designed an instructions related to lymphedema prevention principles for women post mastectomy after reviewing the related literature according to patients needs identified in the assessment. Experts in nursing and medical fields in general and oncology management revised the content for ensuring its clarity, relevancy and applicability for study group only.

Implementation:

In this step an instructions related to lymphedema prevention principles was given for study group only and their relatives in outpatient clinic on oncology department in the form of knowledge related to lymphedema and its prevention principles after mastectomy through using different teaching methods as lecture and open discussion by using illustrative pictures and computer video, then demonstration and redemonstration for performing exercise program in four session each one took from 45-60 minutes. Each session had ten patients and the available relatives if present. In the first and second session the researchers started to identify the purpose of the research and giving knowledge related to lymphedema prevention principles and giving each patient simplified booklet contain an instructions related to lymphedema prevention principles by using illustrative pictures for illiterate patients then at the end of the second session the researchers revised the knowledge that was given through open discussion and asking questions with the patients. In the third and fourth session the researchers started to learn patients post mastectomy exercises for prevention of lymphedema through demonstration and redemonstration by using observational checklist to ensure that the patient become competent while performing the exercises. The researchers contacted with each patient of the study group at least two times per week for about two months during patient hospitalization and routine follow up in outpatient clinic then through telephone after patient discharge to insure understanding of knowledge and skills that was given and answering for patient questions if present. The control group was exposed only to routine hospital care

Evaluation:

Each patient of the study and control group was evaluated two times: The first one is in the assessment by using instruments 1 (part I, II and III), 2 and 3. The second evaluation was done two month post implementation of lymphedema prevention principles by using instruments 1 (part III), 2 and 3. Then comparison was done between study and control group in relation to knowledge and application of lymphedema prevention principles.

2.6. Statistical analysis:

Data were collected and analyzed statistically by using an IBM personal computer with Statistical Package of Social Science (SPSS) version 20 in the form of:

1. Descriptive statistics:

in which quantitative data were presented in the form of mean and standard deviation and qualitative data were presented in the form of numbers and percentages.

2. Analytical statistics:

Used to find out the possible association between studied factors and the targeted disease. The used tests of significance included; chi-square test (χ2) was used to study the association between two qualitative variables. Student t-test: is a test of significance used for comparison between two groups having quantitative variables. P value of > 0.05 non-significant, P value of < 0.05 significant, P value of <0.001 highly significant.

3. RESULTS:

Table (1) demonstrates that more than half of the study sample was between 30 – 50 years old (57.1% and 55.2%) with a mean age of 42.46 ± 9.08 and 43.17 ± 10.14 years old for study and control group respectively. About half of the patients (47.6% and 51.4%) had secondary education for study and control respectively. More than half of the patients (57.1% and 53.3%) were housewife and (53.3% and 51.4%) didn't have enough money for study and control group respectively.

Table (2) shows more than half of the study sample (56.2% and 51.4%) has chronic diseases for study and control group respectively, most of these diseases were diabetes (22.9%) for study group and hypertension (20.0%) for control group. More than half of the study sample didn't have family history of cancer (53.3% and 50.5%) for study and control group respectively.

Table (3) illustrates there was no statistically significant difference between study and control group regarding all items of knowledge assessment about lymphedema and total score knowledge mean pre intervention as p value > 0.05.

Table (4) clarifies that there was highly statistically significant differences between study and control group regarding all items of knowledge assessment about lymphedema and total score knowledge mean post intervention as P value = 0.000.

Table (5) describes the highly statistically significant differences between study and control group regarding application of lymphedema prevention principles post intervention for lifting heavy things by affected arm, avoidance of injuries, avoidance of burns, wearing tight clothes and jewelries, performing lymphedema prevention exercises as P value = 0.000 and there was statistically significant deference between study and control group for careful dealing with household animals as P value = 0.004. While there was not statistically significant difference between study and control group for medical examination as measurement of blood pressure and injection as P value = 0.088.

Table (6) demonstrates more than two third of the study sample (72.4% and 78.0%) perform shoulder function activities with difficulty for study and control groups respectively with no statistically significant differences pre intervention as P value = 0.53 that improved in the post intervention for study group (49.5%) perform shoulder function activities with mild compromise and (36.2%) perform shoulder function activities normally than control group.

Table (7) shows there was highly statistically significant differences between study and control group regarding functional status mean score in relation to personal, occupational, familial, social activities as P value = 0.000.

Table (1): Socio demographic characteristics of studied groups (N=210):

Socio demographic

Characteristics

Study (N=105)

Control (N=105)

χ2

p value

No.

Age:

less than 30

30-50

more than 50

16.2

57.1

26.7

14.3

55.2

30.5

0.43

0.81 (NS)

Age / years ( ±SD):

42.46±9.08

43.17±10.14

t- test= 0.54

p value= 0.59 (NS)

Level of education:

Illiterate

Read and write

Primary education

Secondary education

Higher education

1.9

8.6

10.5

47.6

31.4

4.8

9.5

12.4

51.4

21.9

3.44

0.49 (NS)

Occupation:

Manual work

Administrative work

Housewife

14.3

28.6

57.1

19.1

27.6

53.3

0.87

0.65 (NS)

Income:

- Enough

- Not enough

46.7

53.3

48.6

51.4

1.02

0.60 (NS)

Significance P value < 0.05 NS: non-significant

Table (2): Percentage distribution for medical data of studied groups (N=210).

Medical data

Study (N=105)

Control (N=105)

χ²

p value

No.

Presence of chronic diseases:

Yes

56.2

43.8

51.4

48.6

0.48

0.49 (NS)

Types of chronic diseases:

Diabetes

Hypertension

Peptic ulcer

Asthma

22.9

18.1

9.5

5.7

43.8

18.0

20.0

6.7

48.6

1.55

0.82 (NS)

Family history of cancer

yes

53.3

46.7

50.5

49.5

0.31

0.58 (NS)

Significance P value < 0.05 NS: non-significant

Table (3): Knowledge assessment related to lymphedema pre intervention among studied group (N=210):

Knowledge assessment

Study (N=105)

Control (N=105)

χ²

p value

No.

Definition of lymphatic system:

Complete correct answer

Incomplete correct answer

Incorrect answer

27.6

19.1

53.3

34.3

15.2

50.5

1.28

0.53 (NS)

Definition of lymphedema:

Complete correct answer

Incomplete correct answer

Incorrect answer

21.0

16.2

62.8

22.9

10.4

66.7

1.49

0.48 (NS)

Causes of lymphedema:

Complete correct answer

Incomplete correct answer

Incorrect answer

4.8

62.8

32.4

7.6

67.6

24.8

1.94

0.38 (NS)

Signs and symptoms of lymphedema:

Complete correct answer

Incomplete correct answer

Incorrect answer

23.8

11.4

64.8

22.9

21.0

56.1

3.60

0.17 (NS)

Prevention of lymphedema:

Complete correct answer

Incomplete correct answer

Incorrect answer

20.0

6.6

73.3

28.6

7.6

63.8

2.35

0.31 (NS)

Management of lymphedema:

Complete correct answer

Incomplete correct answer

Incorrect answer

16.2

12.4

71.4

13.3

12.4

74.3

0.35

0.84 (NS)

Total score ( ±SD):

2.97±2.0

2.89±1.5

t- test= 0.34

p value= 0.74 (NS)

Significance P value < 0.05 NS: non-significant

Table (4): Knowledge assessment related to lymphedema post intervention among studied group (N=210):

Knowledge assessment

Study (N=105)

Control (N=105)

χ²

p value

No.

Definition of lymphatic system:

Complete correct answer

Incomplete correct answer

Incorrect answer

80.0

16.2

3.8

15.2

38.1

46.7

93.73

0.000 (HS)

Definition of lymphedema:

Complete correct answer

Incomplete correct answer

Incorrect answer

81.9

12.4

5.7

9.5

27.6

62.9

1.16

0.000 (HS)

Causes of lymphedema:

Complete correct answer

Incomplete correct answer

Incorrect answer

80.0

20.0

0.00

23.8

27.6

48.6

84.22

0.000 (HS)

Signs and symptoms of lymphedema:

Complete correct answer

Incomplete correct answer

Incorrect answer

77.1

19.1

3.8

`19.1

32.3

48.6

85.38

0.000 (HS)

Prevention of lymphedema:

Complete correct answer

Incomplete correct answer

Incorrect answer

74.3

22.8

2.9

26.7

34.3

39.0

69.17

0.000 (HS)

Management of lymphedema:

Complete correct answer

Incomplete correct answer

Incorrect answer

74.3

23.8

1.9

26.7

39.0

34.3

62.47

0.000 (HS)

Total score ( ±SD):

10.64 ± 1.29

4.44 ± 3.10

t- test= 18.94

p value= 0.000 (HS)

Significance P value < 0.05 HS: highly significant

Table (5): Application of lymphedema prevention principles post intervention among studied groups (N=210):

Application of lymphedema prevention principles

Study (N=105)

Control (N=105)

χ²

p value

No.

Lifting heavy things by affected arm:

Always

Sometimes

Never

3.8

21.9

74.3

6.7

58.1

35.2

32.63

0.000 (HS)

Avoidance of burns:

Always

Sometimes

Never

1.9

7.6

90.5

14.3

49.5

36.2

64.02

0.000 (HS)

Avoidance of injuries:

Always

Sometimes

Never

4.8

11.4

83.8

8.6

54.3

37.1

49.40

0.000 (HS)

Wearing tight clothes and jewelries:

Always

Sometimes

Never

2.9

19.1

78.1

6.7

53.3

40.0

31.56

0.000 (HS)

Careful dealing with household animals:

Always

Sometimes

Never

1.0

7.6

91.4

2.9

22.9

74.2

10.86

0.004 (S)

medical examination (measurement of blood pressure and injection:

Always

Sometimes

Never

100

1.9

2.9

95.2

3.8

9.5

86.7

4.86

0.088 (NS)

Performing lymphedema prevention exercises:

Always

Sometimes

Never

86.6

10.5

2.9

12.4

32.4

55.2

119.80

0.000 (HS)

Significance P value<0.05 NS: non-significant HS: highly significant

Table (6): Shoulder functional ability pre and post intervention among studied groups (N=210):

Shoulder functional ability

Study (N=105)

Control (N=105)

χ²

p value

No.

Pre-intervention

Normal

Mild compromise

With difficulty

Only with assistance

6.7

5.7

72.4

15.2

2.9

6.7

78.0

12.4

2.22

0.53 (NS)

Post-intervention

Normal

Mild compromise

With difficulty

Only with assistance

36.2

49.5

9.5

4.8

9.5

22.0

55.2

13.3

18.19

0.000 (HS)

Significance P value<0.05 NS: non-significant HS: highly significant

Table (7): Mean and standard deviation to functional status score for studied groups pre and post intervention

Functional Status

Study (N=105)

( ±SD)

Control (N=105)

( ±SD)

t-test

p value

Personal activities

Pre intervention

Post intervention

14.50±2.08

31.02±4.49

14.05±2.20

19.92±2.64

1.52

21.82

0.13 (NS)

0.00 (HS)

Occupational activities

Pre intervention

Post intervention

17.06±3.01

25.54±2.30

16.52±2.33

17.41±2.05

1.44

27.10

0.15 (NS)

0.00 (HS)

Familial activities

Pre intervention

Post intervention

20.04±4.24

37.44±7.18

20.89±3.71

22.59±3.36

1.54

19.19

0.12 (NS)

0.00 (HS)

Social activities

Pre intervention

Post intervention

9.89 ±2.70

19.83±2.17

9.67±2.09

10.52±2.31

0.66

30.02

0.51 (NS)

0.00 (HS)

Total functional status

Pre intervention

Post intervention

62.96±7.01

113.84±9.30

61.57±5.30

70.39±4.87

1.62

42.41

0.11 (NS)

0.00 (HS)

4. DISCUSSION:

Breast cancer is the most common cancer that leading to death among women. Surgical treatment is considered the most common method of treatment that women is exposed to it for breast cancer management which result in several complications postoperatively such as, impairment of movement and pain in the affected shoulder, body image disturbance and lymphedema that affect in the functional status for woman. Therefore our study was conducted to assess shoulder function, functional status and knowledge after application of lymphedema prevention principles among women post mastectomy.

Regarding sociodemographic characteristics and medical data among studied groups:

The result of the present study revealed that more than half of the study sample was between 30 – 50 years old with the mean age of 42.46 and 43.17 years old for study and control group respectively. This finding is on the same line with Pandey, et al¹⁸. They found that the mean age of the women was 45.6 years with the range of age from 17–80 years from their study for two hundred and fifty four women with breast cancer. Also El Sayed and Badr ¹⁹ concluded that the mean age of breast cancer women was 43.81 with the age ranged from 30-60 years old. Winnie et al.²⁰reported finding contrasted to our study that the mean age of breast cancer women was 51.7 years. About half of the patients (47.6% and 51.4%) had secondary education for study and control group respectively. More than half of the patients (57.1% and 53.3%) were housewife and didn't has family history of cancer (53.3% and 50.5%) for study and control group respectively. This finding is consistence with Winnie et al.²⁰_and El Sayed and Badr ¹⁹ they found that around half of breast cancer women in their study were married, had a secondary education and didn't have work.

Concerning knowledge assessment about lymphedema for application of lymphedema prevention principles among studied groups:

The current study concluded that there was highly statistically significant differences between study and control group regarding all items of knowledge assessment about lymphedema and application of lymphedema prevention principles for lifting heavy things by affected arm, avoidance of injuries, avoidance of burns, wearing tight clothes and jewelries, performing lymphedema prevention exercises post intervention. This result is consistent with Golshan and Smith²¹. as they reported that breast cancer patients should be educated the principles of preventive and prophylactic activities post mastectomy by an oncologist and nurses for prevention of complications. Also Moseley et al.,²² reported that implementation of lymphedema preventive measures early postoperatively may result in decreasing or postpone the development of it. On the same line Zuther²³ emphasized that implementing postoperative exercise and preventive measures for lymphedema have beneficial effects for prevention of lymphedema post mastectomy.

Considering shoulder function among studied groups:

The result of the present study reported that there was highly statistically significant improvement in performing shoulder function activities for study group than control group. This result from the researchers' opinion was through application of upper limb exercises for prevention of lymphedema. This result was supported by Eyigor et al²⁴ they reported that performing exercises among breast cancer women post mastectomy have a significant effects on reducing fatigue, increasing shoulder function and quality of life for study group than control group. McNeely, et al. ²⁵, and Mohammed ²⁶ reported implementation of physical therapy and exercise for shoulder after breast cancer surgery leading to improvement of shoulder function and range of motion exercise for women.

Regarding functional status among studied groups:

The result of the present study reported that there was highly statistically significant improvement in functional status mean score in relation to personal, occupational, familial, social activities for study group than control group. This result from the researcher's opinion was through increasing patient's knowledge and application of lymphedema prevention principles. This finding is consistent with Ajay et al., ²⁷ they reported that improvement of breast cancer patients quality of life from all aspects that include physical, psychological, emotional and social wellbeing and reducing pain, discomfort and heaviness of the affected arm through application of exercises program post mastectomy. Also Simpson et al.,²⁸and El Sayed and Badr ¹⁹ found that functional status and the disease stage among breast cancer patient was positively affected by educational level, adequacy of financial state, comorbidity and marital state.

At the end, the results of the present study revealed a significant improvement in shoulder function and functional status through increasing knowledge and application of lymphedema prevention principles among women post mastectomy, so our research hypothesis was achieved.

5. CONCLUSIONS:

Application of lymphedema prevention principles is very important concern to increase knowledge and improve shoulder function and functional status for women post mastectomy.

6. RECOMMENDATIONS:

Nurses should pay an attention to educate lymphedema prevention principles for women post mastectomy to improve their shoulder function and functional status.

7. REFERENCES:

1. Sharif Nia H, Pahlevan Sharif S, Lehto RH, et al (2017). Development and psychometric evaluation of a Persian version of the death depression scale-revised: a cross-cultural adaptation for patients with advanced cancer. Jpn J Clin Oncol, 47, 713-9.

2. Torre LA, Bray F, Siegel RL, et al (2015). Global cancer statistics, 2012. CA Cancer J Clin, 65, 87-108.

3. Ferlay J, Shin HR, Bray F, et al (2010). Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer, 127, 2893-917.

4. World Health Organization (2017). Breast cancer burden [Online]. Available at: http://www.who.int/cancer/detection/ breastcancer/en/index1.html.

5. Veronesi U, Stafyla V, Petit JY, Veronesi P. Conservative mastectomy: extending the idea of breast conservation. Lancet Oncol. 2012 Jul; 13(7):e311-7.

6. Gosselink R, Rouffaer L, Vanhelden P, Piot W, Troosters T, Christiaens M-R. Recovery of upper limb function after axillary dissection. Journal of Surgical Oncology 2003; 83:204–11.

7. Campbell KL, Pusic AL, Zucker DS, McNeely ML, Binkley JM, Cheville AL, et al. A prospective model of care for breast cancer rehabilitation: function. Cancer. 2012; 118(8 Suppl):2300-11.

8. Gilchrist LS, Galantino ML, Wampler M, Marchese VG, Morris GS, Ness KK. A framework for assessment in oncology rehabilitation. Phys Ther. 2009; 89(3):286-306.

9. Fann JR, Thomas-Rich AM, Katon WJ, et al (2008). Major depression after breast cancer: a review of epidemiology and treatment. Gen Hosp Psychiatry, 30, 112-26.

10. 26. Gosselink R, Rouffaer L, Vanhelden P, Piot W, Troosters T, Christiaens M-R. Recovery of upper limb function after axillary dissection. Journal of Surgical Oncology 2003;83:204–11.

11. J.M. Armer J.M., Stewart B. R. Post-breast cancer lymphedema: incidence increases from 12 to 30 to 60 months, Lymphology, 43 (3) (2010), pp. 118-127

12. Hayes S.C., Johansson K., Stout N.L., Prosnitz R., Armer J.M., Gabram S., Upper-body morbidity after breast cancer: incidence and evidence for evaluation, prevention, and management within a prospective surveillance model of care, Cancer, 15 (118) (2012), pp. 2237-2249, 10.1002/cncr.27467

13. Pain SJ, Purushotham AD. Lymphoedema following surgery for breast cancer. Br J Surgery 2000; 87: 1128-1141.

14. Woods M, Tobin M, Mortimer P. The psychosocial morbidity of breast cancer patients with lymphedema. Cancer Nurs, 1995; 18: 467-471.

15. McRae,R. (2004). Clinical orthopedic examination, 5^th ed., london, churchill living stone company, 57.

16. Tulman L., Fawcett J. and ncEvoy M.D. (1991). Development of the inventory of functional status of cancer, Cancer Nurs., 14(5); 254-60.

17. Mohamed S. (2001). Correlates of functional status profile among cancer patient on chemotherapy, unpublished master thesis, Faculty of Nursing, Cairo University.

18. Pandey M, Thomas BC, Ramdas K et al. (2006). Early Effect of Surgery on Quality of Life in Women with Operable Breast Cancer. Japanese Journal of Clinical Oncology, Volume 36 Issue 7, 468-472.

19. El Sayed S. A. and Badr S. A. (2014). Depressive Symptoms and Anxiety: Relationship to Social Support and Functional Status among Patients with Breast Cancer Surgery. IOSR Journal of Nursing and Health Science, Volume 3, Issue 4, 54-63.

20. Winnie K.W., Gene Marsh, W.M. et al. (2010). Anxiety, depression and quality of life among Chinese breast cancer patients during adjuvant therapy. European Journal of Oncology Nursing, 14 , 17–22.

21. Golshan M, Smith B. Prevention and management of arm lymphedema in the patient with breast cancer. J Support Oncol. 2006 Sep;4(8):381-6.

22. Moseley AL, Piller NB, Carati CJ. The effect of gentle arm exercise and deep breathing on secondary arm lymphedema. Lymphology. 2005 Sep; 38(3):136-45.

23. Zuther E. Lymphedema management: the comprehensive guide for practitioners. Thieme Medical Publishers, New York 2005: p.218-22.

24. Eyigor S, Karapolat H, Yesil H, Uslu R, Durmaz B. Effects of pilates exercises on functional capacity, flexibility, fatigue, depression and quality of life in female breast cancer patients: a randomizedcontrolled study. Eur J Phys Rehabil Med. 2010;46:481–487.

25. McNeely ML, Campbell K, Ospina M, et al. Exercise interventions for upper-limb dysfunction due to breast cancer treatment. Cochrane Database Syst Rev. 2010 Jun 16;(6):CD005211.

26. Mohammed S.A. Effects of exercise intervention on pain, shoulder movement, and functional status in women after breast cancer surgery: A Randomized Controlled Trial, Journal of Education and Practice, 2016, 7 (.8): 97-108.

27. Ajay P. Gautam, Arun G. Maiya, Mamidipudi S. Vidyasagar, Effect of home-based exercise program on lymphedema and quality of life in female postmastectomy patients: Pre-post intervention study, Journal of Rehabilitation Research and Development, Volume 48, Number 10, 2011, 1261–1268.

28. Simpson JS, Carlson LE, Beck CA, et al (2002). Effects of a brief intervention on social support and psychiatric morbidity in breast cancer patients. Psycho oncology, 11, 282-94.

Received on 27.07.2018 Modified on 02.08.2018

Asian J. Nursing Education and Research. 2018; 8(4):453-461.

DOI: 10.5958/2349-2996.2018.00092.7