Effects of physiotherapy methods in post-operative women with breast cancer: systematic review with meta-analysis

Sousa, Amanda Eduarda da Costa; Linhares, Diego Gama; Nunes, André Salin de Menezes; Pinto, Camilly Eduarda da Cruz; Nascimento, Rodolfo Gomes do; Borba-Pinheiro, Claudio Joaquim

doi:10.1590/fm.2025.38202

person Amanda Eduarda da Costa Sousa

were responsible for the conceptualization · for the formal analysis and original draft · for the investigation · All authors were responsible for the methodology and approved the final version

schoolUniversidade do Estado do Pará (UEPA), Tucuruí, PA, Brazil

0000-0003-4012-4625

person Diego Gama Linhares *

were responsible for the conceptualization · for the formal analysis and original draft · for the investigation · for the supervision · All authors were responsible for the methodology and approved the final version

school Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil

0000-0002-2901-3273

person André Salin de Menezes Nunes

were responsible for the conceptualization · for the investigation · for the supervision · All authors were responsible for the methodology and approved the final version

schoolUniversidade do Estado do Pará (UEPA), Tucuruí, PA, Brazil

0009-0001-6780-6856

person Camilly Eduarda da Cruz Pinto

were responsible for the conceptualization · for the investigation · All authors were responsible for the methodology and approved the final version

schoolUniversidade do Estado do Pará (UEPA), Tucuruí, PA, Brazil

0000-0001-5593-0000

person Rodolfo Gomes do Nascimento

for the supervision · for the validation · All authors were responsible for the methodology and ap-proved the final version

schoolUniversidade do Estado do Pará (UEPA), Tucuruí, PA, Brazil

0000-0002-6170-2618

person Claudio Joaquim Borba-Pinheiro

for the supervision · for the validation · All authors were responsible for the methodology and ap-proved the final version

schoolUniversidade do Estado do Pará (UEPA), Tucuruí, PA, Brazil

0000-0002-9749-5825

person*Correspondence: diegamalin@gmail.com

Associate editor:

Patricia Viana da Rosa

Certainty assessment					Effect (95% CI)		Certainty	Importance
Studies*	Risk of bias	Inconsistency	Indirectness	Imprecision	Relative	Absolute	Certainty	Importance
Abduction RT = 3 EG = 132 CG = 145	Serious	Serious^a	Not serious	Not serious	-	SMD 1.21 higher (0.41 lower to 2.82 higher	⨁⨁◯◯ Low	Important
Flexion RT = 3 EG = 132 CG = 143	Serious	Serious^a	Not serious	Not serious	-	SMD 1.48 higher (0.35 lower to 3.31 higher)	⨁⨁◯◯ Low	Important

Authors	Sample	Intervention method	Exercise protocols	Assessment instrument
Kilbreath et al.¹⁶	160 women BC; 52.5 age EG (n = 81): age = 53.5 ± 12.1 CG (n = 79): age = 51.6 ± 11.0	Kinesiotherapy with radiation therapy and passive stretching	EG: Supervised exercises with a weekly session for 8 weeks, started 4-6 weeks post- operatively. GC: Written information on exercises and encouragement to use your arm.	Pre-intervention and after 8 weeks and 6 months, evaluating a range of movement, muscle strength, lymphedema, a questionnaire to assess the quality of life (EORTC-BR23) and symptoms in the affected limb (4-point scale) was applied.
Testa et al.¹⁷	70 women BC; 51 age EG (n = 35): age = 54.3 ± 11.2 CG (n = 35): age = 55.3 ± 10.1	Kinesiotherapy	EG: One-year Exercise Program with 60 minutes per session, 5 times/week, 20 sessions, started immediately post-operatively. GC: Not submitted to physiotherapeutic procedures.	Preoperative and postoperative 5 days, 1, 6, and 12 months, goniometry, visual analog scale, and EORTC QLQ-BR23 questionnaire were used.
Sato et al.¹⁸	149 women BC; 53.2 age ALND EG (n = 39): age = 52.9 ± 10.1; CG (n = 30): age = 52.1 ± 12.9 SLNB EG (n = 51): age = 54.6 ± 10.6; CG (n = 29): age = 53.7 ± 9.5	Educational physiotherapy + kinesiotherapy	EG: Educational program monitoring arm function and exercises to prevent shoulder dysfunction and lymphedema at 3 months, started in preoperative patients. GC: They received routine care on-site and were informed about the upper limb extremity function results determined in the survey.	Goniometry (shoulder flexion, horizontal extension, and abduction); Hand dynamometer; Perimeter of the upper limbs; SPOFIA questionnaire; DASH questionnaire.
De Groef et al.¹⁹	50 women BC; 54.2 age EG (n = 25): age = 55.3 ± 7.5 CG (n = 25): age = 53.1 ± 7.5	Myofascial facilitation + traditional physiotherapy	EG: 12 sessions myofascial release (1 time/week, 30min) + Traditional physiotherapy 2 sessions/week (30min), started 4-6 weeks post- operatively. 1 - Passive mobilization of the shoulder to active shoulder ROM; 2 - Stretching of the pectorals, muscular flexibility, and passive and active shoulder. ROM; 3 - Scar tissue massage for scar flexibility; and 4 - Exercise regimens for muscular flexibility, endurance, strength, scapula-thoracic control, and ROM shoulder activity. Intervention time 12 weeks. CG: static bilateral activities for hands, upper body, and arm. The CG placebo session lasted 30 minutes, with a frequency of once/week for 12 weeks.	Active shoulder ROM (inclinometer); Arm lymphedema; Muscular strength (portable dynamometer); Perimetry (metallic tape), Scapular statics and dynamics; shoulder function (disability questionnaire); SF-36 QoL.
Klein et al.²⁰	157 women BC; 52.2 age EG (n = 72): age = 53.3 ± 12.7 CG (n = 85): age = 51.2 ± 13.1	Pre-physiotherapy	EG: 3 sessions/week, 5 repetitions for each exercise until maximum function and ROM were restored without pain. The intervention was performed on patients 1 month and 6 months post-operatively. CG: Did not undergo physical therapy procedures.	Pain, functionality of the upper limbs, and degrees of flexion and abduction ROM.
Bruce et al.²¹	350 women BC; 58.1 age EG (n = 175): age = 58.4 ± 12.4 CG (n = 175): age = 57.8 ± 12.0	Kinesiotherapy	EG: Three levels of elastic band (1.1 kg; 1.7 kg; 2.6 kg). Three physiotherapy sessions lasting 7 to 10 days. Varied intensities. Total time 12 months of intervention, started in preoperative patients. CG: Subjected to routine day-to-day care.	Upper limb function (arm, hand, and shoulder), pain, wound- related complications, and QoL.

Authors	Objective	Study design	Results (p < 0.05)	Conclusion
Kilbreath et al.¹⁶	Verify the effects of a combined program on pain, discomfort, joint stiffness, and muscle weakness without causing lymphedema.	Randomized clinical trial	In the EG, the ROM of the UL homolateral to the surgery was greater than that of the CG in all evaluations. Regarding lymphedema, no differences were observed between the groups.	The kinesiotherapy program was effective in controlling the mobility variables of the ipsilateral UL, pain, discomfort, joint stiffness, and muscle weakness without causing lymphedema. (4-point scale) was applied.
Testa et al.¹⁷	To evaluate the effectiveness of the early physical rehabilitation program as a treatment for joint mobility and improvement of QoL.	Randomized clinical trial	EG recovered normal function of the variables studied within 1 year after surgery, which did not occur with the CG. The EG showed general improvement in QoL.	The procedure performed recovered the mobility of the glenohumeral joint, improving the functional autonomy of the UL and QoL after one year of physiotherapeutic treatment.
Sato et al.¹⁸	1. To investigate the effectiveness of a perioperative educational program in improving arm dysfunction in BC patients. 2. To investigate the effect of myofascial therapy in addition to a standard physical therapy program for the treatment of UL dysfunction in BC survivors.	Randomized clinical trial	Only SPOFIA and grip strength improved in EG with ALND. In contrast, the perioperative educational program did not cause improvement for patients undergoing surgery with SLNB.	The educational exercise program to prevent shoulder dysfunction and lymphedema was effective. SPOFIA and grip strength improved (p < 0.05) in EG with ALND. Thus, the present program improves postoperative arm function and discomfort in BC patients undergoing ALND surgery.
De Groef et al.¹⁹	The aim of this study was to investigate the effect of myofascial therapy in addition to a standard physiotherapy program for the treatment of UL dysfunctions in breast cancer survivors.	Clinical trial	No differences were found between groups for all outcome parameters over 12 months. However, the overall benefits of standard physical therapy for active shoulder ROM and shoulder function improved in both groups.	Myofascial therapy did not have an additional beneficial effect in improving UL function in women after BC surgery.
Klein et al.²⁰	Examine the effect of early physical therapy and patient education on these morbidities.	Clinical trial	GE reduced pain levels in the first month. Minor and extensive surgeries showed an additional effect for the intervention six months after surgery on functional disabilities.	Early physical therapy and patient education have reduced pain levels and can improve functional disabilities without causing postoperative complications.
Bruce et al.²¹	To investigate the effects of an exercise program compared to usual care best practices for women at high risk of UL disability following treatment for BC.	Randomized clinical trial	The PROSPER exercise EG improved upper limb function, postoperative pain, arm symptoms, and physical QoL at 12 months compared to the CG.	The structured and progressive early exercise was safe and clinically effective for women at high risk of developing shoulder and upper limb problems after non-reconstructive breast surgery.

[TFN1] Note: *Study design (RT = randomised trials), number of studies, and number of patients in experimental (EG) and control (CG) groups. CI = confidence interval; SMD = standard mean difference. ^aThe high heterogeneity can be explained by the use of different evaluation methods, but was corrected with the use of the random effects model.

Effects of physiotherapy methods in post-operative women with breast cancer: systematic review with meta-analysis

Efeitos dos métodos fisioterapêuticos em mulheres pós-operatórias com câncer de mama: revisão sistemática com meta-análise

Abstract